House Hearing, 113TH Congress - Safety For Survivors: Care and Treatment For Military Sexual Trauma

SAFETY FOR SURVIVORS: CARE AND TREATMENT
FOR MILITARY SEXUAL TRAUMA
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON VETERANS AFFAIRS

U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRTEENTH CONGRESS
FIRST SESSION
FRIDAY, JULY 19, 2013
Serial No. 11331

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COMMITTEE ON VETERANS AFFAIRS

JEFF MILLER, Florida, Chairman
DOUG LAMBORN, Colorado
GUS M. BILIRAKIS, Florida
DAVID P. ROE, Tennessee
BILL FLORES, Texas
JEFF DENHAM, California
JON RUNYAN, New Jersey
DAN BENISHEK, Michigan
TIM HUELSKAMP, Kansas
MARK E. AMODEI, Nevada
MIKE COFFMAN, Colorado
BRAD R. WENSTRUP, Ohio
PAUL COOK, California
JACKIE WALORSKI, Indiana
MICHAEL H. MICHAUD, Maine, Ranking

Minority Member
CORRINE BROWN, Florida
MARK TAKANO, California
JULIA BROWNLEY, California
DINA TITUS, Nevada
ANN KIRKPATRICK, Arizona
RAUL RUIZ, California
GLORIA NEGRETE MCLEOD, California
ANN M. KUSTER, New Hampshire
BETO OROURKE, Texas
TIMOTHY J. WALZ, Minnesota
HELEN W. TOLAR, Staff Director and Chief Counsel
SUBCOMMITTEE ON HEALTH
DAN BENISHEK, Michigan, Chairman
DAVE P. ROE, Tennessee
JEFF DENHAM, California
TIM HUELSKAMP, Kansas
JACKIE WALORSKI, Indiana
BRAD R. WENSTRUP, Ohio
VACANCY
JULIA BROWNLEY, California, Ranking

Minority Member
CORRINE BROWN, Florida
RAUL RUIZ, California
GLORIA NEGRETE MCLEOD, California
ANN M. KUSTER, New Hampshire
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records
of the Committee on Veterans Affairs are also published in electronic form. The printed
hearing record remains the official version. Because electronic submissions are used to
prepare both printed and electronic versions of the hearing record, the process of converting
between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process
is further refined.
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CONTENTS
July 19, 2013
Page
Safety For Survivors: Care And Treatment For Military Sexual Trauma .........
OPENING STATEMENTS
Hon. Dan Benishek, Chairman, Subcommittee on Health ...................................
Hon. Julia Brownley, Ranking Minority Member, Subcommittee on Health .....
Prepared Statement of Hon. Brownley ...........................................................
Hon. Jackie Walorski, U.S. House of Representative ...........................................
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WITNESSES
Victoria Sanders, Veteran .......................................................................................
Prepared Statement of Ms. Sanders ...............................................................
Lisa Wilken, Veteran .......................................................................................
Prepared Statement of Ms. Wilken .................................................................
Brian Lewis, Veteran .......................................................................................
Prepared Statement of Mr. Lewis ...................................................................
Tara Johnson, Veteran .....................................................................................
Prepared Statement of Ms. Johnson ...............................................................
Michael Shepherd M.D., Physician, Office of Health Care Inspections, Office
of the Inspector General, U.S. Department of Veterans Affairs ......................
Prepared Statement of Dr. Shepherd .....................................................................
Accompanied by:
Karen McGoff-Yost, LCSW, Associate Director, Bay Pines Office of
Healthcare Inspections, Office of the Inspector General, U.S. Department of Veterans Affairs
Jonathan M. Farrell-Higgins, Ph.D., Chief, Stress Disorder Treatment Program, Colmery-ONeil VA Medical Center, VA Eastern Kansas Health Care
System, Veterans Integrated Service Network 15, Veterans Health Administration, U.S. Department of Veterans Affairs .................................................
Carol OBrien, Ph.D., Chief, Post Traumatic Stress Disorder Programs, Bay
Pines VA Healthcare System, Veterans Integrated Service Network 8, Veterans Health Administration, U.S. Department of Veterans Affairs ..............
Rajiv Jain, M.D., Assistant Deputy Undersecretary for Patient Care Services,
Office of Patient Care Services, Veterans Health Administration, U.S. Department of Veterans Affairs, Prepared Statement only ..................................
Accompanied by:
David Carroll, Ph.D., Acting Chief Consultant, Mental Health Services,
Office of Patient Care Services, Veterans Health Administration,
U.S. Department of Veterans Affairs
Stacey Pollack, Ph.D., National Mental Health Director of Program
Policy Implementation, Mental Health Services, Office of Patient
Care Services, Veterans Health Administration, U.S. Department
of Veterans Affairs
Karen S. Guice, M.D., M.P.P., Principal Deputy Assistant Secretary of Defense for Health Affairs, Office of Health Affairs, U.S. Department of Defense, Prepared Statement only ..........................................................................
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STATEMENTS FOR THE RECORD
The American Legion ..............................................................................................

Disabled American Veterans (DAV) on Behalf of the Independent Budget .......
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QUESTIONS FOR THE RECORD
Letter From: Hon. Julia Brownley, Ranking Member, Subcommittee on

Health, To: Hon. Eric K. Shinseki, Secretary, U.S. Department of Veterans
Affairs ....................................................................................................................
Questions from Rep. Dina Titus, U.S. House of Representatives ........................
Health, To: Hon. George J. Opfer, Inspector General, Department of Veterans Affairs .........................................................................................................
Questions from Rep. Dina Titus, U.S. House of Representatives ........................
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SAFETY FOR SURVIVORS: CARE AND

TREATMENT FOR MILITARY SEXUAL TRAUMA
Friday, July 19, 2013
U.S. HOUSE OF REPRESENTATIVES,

COMMITTEE ON VETERANS AFFAIRS,
SUBCOMMITTEE ON HEALTH,
Washington, D.C.
The Subcommittee met, pursuant to notice, at 9:57 a.m., in Room
334, Cannon House Office Building, Hon. Dan Benishek [Chairman
of the Subcommittee] presiding.
Present: Representatives Benishek, Roe, Denham, Wenstrup,
Walorski, Brownley, Ruiz, and Kuster.
Also present: Representatives Kirkpatrick, ORourke, and Speier.
OPENING STATEMENT OF CHAIRMAN DAN BENISHEK
Mr. BENISHEK. Good morning, everyone. The Subcommittee will

come to order. Before we begin, I would like to ask unanimous consent for my friends and fellow Committee Members, Gus Bilirakis,
Ann Kirkpatrick, Dina Titus, Tim Walz, Beto ORourke, and Doug
Lamborn, and our colleague Jackie Speier, to sit at the dais and
participate in todays proceedings. Without objection, so ordered.
With that, I welcome you to todays hearing, Safety for Survivors: Care and Treatment for Military Sexual Trauma. I am
grateful to you all for being here today.
When the men and women of our armed forces sign up to defend
our freedom, they willingly accept the threat of danger from our enemies. But what they should never have to accept is the threat of
sexual assault from their fellow servicemembers. Perpetrators of
military sexual trauma should be aggressively pursued, prosecuted,
and punished. I, along with many of my colleagues here, are working to advance legislation to reform and improve the military justice system. Just as important as that effort, however, is the one
we turn to today: listening to, caring for, and supporting the healing of those who have suffered this terrible crime.
According to the DoD, there were roughly 38 incidents of sexual
assault among male servicemembers and 33 incidents of sexual assault among female servicemembers per day last fiscal year. Let
me repeat, last fiscal year that were roughly 71 incidents of sexual
assault every single day among those who wear our uniform. To
say this is unacceptable does not adequately describe the terrible
reality of military sexual assault and the lasting effects it can have
on the lives of those who experience it. A servicemember who is a
victim of sexual assault is often hesitant to disclose their experience or seek the supportive services that they need and deserve.
While this is troubling to me, it is even more troubling to listen
to the personal stories of those who have taken the brave step to
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come forward and find that those departments tasked with caring
for them, the Department of Veterans Affairs and the Department
of Defense are unresponsive, uncoordinated, and unable to meet
their obligations to these survivors.
In January of this year, the Government Accountability Office
issued a report which found, among other things, that DoD sexual
assault coordinators, who are allegedly the single point of contact
for sexual assault survivors, and who are tasked with managing
their medical needs within the Department of Defense are, quote,
not always aware of the health care services available to sexual
assault victims at their respective locations. The GAO also found
that military health care providers did not have a consistent understanding of their responsibilities to care for sexual assault victims.
Further, a VA Inspector General report issued last December
found that, among other things, VAs military sexual trauma coordinators, who are the single point of contact for veterans who have
experienced military sexual trauma within VA facilities, report as
little as 2 hours a week to conduct outreach to and monitoring of
those veterans who have screened positive for military sexual trauma.
What confidence can assault survivors have when, at their lowest
moment, DoD and VA fail to understand their own responsibilities
to provide care, fail to provide the health care options that are
available, and fail to empower their most direct point of contact
with the knowledge, authority, and the tools to be effective, not just
present?
The answer to that question lies in the voices of our veterans
themselves. In preparing for this hearing, we spoke with many veteran survivors of military sexual trauma and those who work closely with them. Their frustrations and concerns were legion. I am
honored to have four such veterans with us this morning. These
veterans represent four branches of the services, the Army, the Air
Force, the Navy, and the Marine Corps, and eras of service from
the Vietnam war to the conflicts in Iraq and Afghanistan.
These brave men and women have endured firsthand the heartbreak and pain associated with military sexual trauma. They know
better than anyone how very long and difficult the journey to healing can be. Each of them has braved public scrutiny and the reliving of very painful memories to be here today, to share with us
their experiences, in the hopes that we might do better for those
that come after them.
Your contribution here today will bring out of the shadows and
into the light a much-needed call for change. I thank each of you
for your honorable service to our Nation and to your fellow veterans, a service which began in uniform years ago and continues
here today.
I will now yield to our Ranking Member, Julia Brownley, for any
opening statement she may have.
OPENING STATEMENT OF HON. JULIA BROWNLEY
Ms. BROWNLEY. Thank you, Mr. Chair.

And good morning to everyone. I would like to thank all of you
for attending todays hearing focused on examining the care and
treatment available to survivors of military sexual trauma. The
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Subcommittee will also be looking at the coordination of care and

services offered to the victims of MST through the Department of
Veterans Affairs and the Department of Defense.
Many MST victims who have suffered through an ordeal such as
sexual assault, oftentimes, are reluctant to discuss their situation
and seek help. Those that finally gather the courage to speak up
find that their story is often dismissed or treated indifferently, unjustly, becoming the victim again.
As many of you know, the Pentagon reported earlier this year
that an estimated 26,000 cases of unwanted sexual contact occurred in 2012, up from 19,000 in 2011. With only 13.5 percent of
incidents reported, it is clear that we must do a better job in both
preventing and treating MST. These servicemembers and veterans
often continue to experience debilitating physical and mental symptoms from MST which can follow them through their lives.
Focusing on prevention, however, is only part of the solution. It
is critical that we do everything that is necessary to do, to make
it easier for victims of MST to access needed benefits and services
and receive treatment. Compassion and care are a significant part
of healing those that have been sexually assaulted.
I applaud the legislative efforts of our colleagues who have introduced legislation, H.R. 1593, the Sexual Assault Training Oversight and Prevention Act, and H.R. 671, the Ruth Moore Act. These
bills seek to ensure stronger protections are in place, so that the
safety and well-being of our men and women in uniform is assured.
We must begin to take these important steps to end sexual assault.
As a proud cosponsor of both bills, I believe we are headed in the
right direction, but we still need to do more.
I was saddened to read the testimonies of our first panel. The
pain and suffering was evident in the personal stories written. I
know that this is hard for all of you, and I commend all of you on
your bravery to speak up and be here today. We need to hear firsthand the experiences of veterans who have found the system unfriendly and intimidating so that we can make it better. I look forward to hearing from our witnesses today.
Again, I thank you for being here. This is a very important issue
for us to tackle here in Congress.
And I thank you, Mr. Chairman, and I now yield back.
[THE PREPARED STATEMENT OF HON. BROWNLEY APPEARS IN THE
APPENDIX]
Mr. BENISHEK. Thank you, Ms. Brownley.
I would now like to formally welcome our first panel to the witness table. Will the panelists please come forward?
Joining us today is Victoria Sanders from Novato, California. Ms.
Sanders is a veteran of the United States Army and a former registered nurse.
Thank you very much for being here and for your service.
I will now yield to my friend and colleague from Indiana, Jackie
Walorski, who will introduce our next veteran witness, Lisa
Wilken.
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OPENING STATEMENT OF HON. JACKIE WALORSKI
Mrs. WALORSKI. Thank you, Mr. Chairman. Thank you for yielding and for your commitment and the commitment we share with
this Committee in addressing this critical issue for the survivors of
military sexual trauma. And I want to thank every Member up
here for voting yes on the whistleblower protection bill that we
passed through the House with a huge bipartisan group, and many
of the cosponsors are sitting here today.
It is my honor to introduce Lisa Wilken from Westfield, Indiana,
a United States Air Force veteran who was sexual assaulted and
consequentially, 100 percent disabled as a result of the trauma endured from her horrific attack. Lisa is more than just a wonderful
wife and a dedicated mother. She is a survivor. She is a survivor
who has made it a mission to bring other victims out of the isolation and the shadows that they suffer through. She is also a veteran, and she has the right to receive access to meaningful treatments.
Lisa, Victoria, Brian, and Tara, thank you for having the courage
to testify before this Committee today. Thank you for your tireless
efforts to hold the VA accountable for treating victims of military
sexual trauma.
Mr. Chairman, I yield back.
Mr. BENISHEK. Thank you, Jackie.
And thank you, Ms. Wilken, for being here today and for your
service.
Our next veteran witness is Brian Lewis from Baltimore, Maryland. Mr. Lewis is a veteran of the United States Navy and a recent graduate of Stevenson University.
Mr. Lewis, thank you very much for being here and thank you
for your service.
We are also joined by Tara Johnson. Ms. Johnson was born and
raised in New Jersey, and currently resides in Lake Mills, Wisconsin. She is a veteran of the United States Marine Corps and
currently serves her fellow veterans as an Army wounded warrior
advocate.
Ms. Johnson, thank you very much for being here, and thank you
for your service.
Ms. Sanders, would you please proceed with your testimony? The
way it works is, you have 5 minutes to testify, and we would like
to try to stick to that, to be polite with our time. Thank you.
STATEMENTS OF VICTORIA SANDERS, VETERAN; LISA
WILKEN, VETERAN; BRIAN LEWIS, VETERAN; AND TARA
JOHNSON, VETERAN
STATEMENT OF VICTORIA SANDERS
Ms. SANDERS. Thank you. Thank you, Mr. Chairman, Representatives and panel. I want to thank you for this chance to speak before this Committee. It is like a birthday gift from Congress because yesterday was my 58th birthday.
Thirty-eight years ago, on my 20th birthday, I arrived at my only
active duty station in Fort Carson, Colorado. One month later, I
was raped. In the middle of the legal battle around the rape, I was
thrown into a custody battle. After basic training, I separated from
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my husband and had one child. No 20-year old private in the military should ever have to fight these battles alone, but that is what
I did. I was diagnosed with PTSD in 2004. It has been a long, hard
road, and I am hoping my testimony today will help me come full
circle.
My rapist confessed to enough of his crimes that he was reduced
in rank, lost pay, and was confined to barracks. This is an example
of chain of command harassment because the barracks he was confined to was the one where I worked and he still worked in the office next door.
When you report a rape you become public enemy number one.
No one will talk to you. And if they do, it is to tell you, you got
what you deserved. You are called names, you internalize what
happened, and it feels like it is your fault. Even if your rapist is
punished, harassment is limitless. It followed me through three
transfers in 9 months.
I had an out because my custody battle made me a single mother. At the time single parents were discharged quickly. They let me
go. But I began the slow decline in mental health known as posttraumatic stress disorder. When you are raped it takes a piece of
your soul. Being raped by a fellow servicemember is a double betrayal, but not being backed up about your commanders is the
hardest betrayal of all.
Because the innocent are treated as criminals, we have lost good
people on each step of this journey. Today, I want to mention two:
Carri Goodwin and Sophie Champoux. They did not live long
enough after being raped to become veterans.
My experience with the VA mental health was at first supportive, caring, trained professionals. We had a great PTSD clinic
in San Jose. I watched it go from a thriving program for both men
and women to a ghost town. I was one of a group of five women
who were not eligible to go for inpatient treatment for various reasons. Dr. Alana Pavar and her student Mylea Charvat started a
process group for the five of us. This is usually only done in an inpatient setting. Three weeks into the program, she was told by her
boss that she could not continue this therapy with us. She did,
however, finish out the 17-week program. She was not going to
leave us. Our world was crushed.
The student who worked with her watched us, and as she
watched she decided to change her focus to trauma, and specifically
military sexual trauma. She went to work at the VA after she completed her studies. Mylea worked there until she was offered a job
at Stanford that allowed her the time to spend with patients, to be
available, and consult for a program in Santa Barbara. It does intensive therapy using EMDR processing therapy and many things
not available at most VA facilities.
This shows me we patients are powerful, but only when we are
allowed to have meaningful therapy, not just the same basic skills.
How many times can a person take the same information in the
same form from a student reading from a book. That is not therapy.
Since I have moved my care to the San Francisco VA, I have only
seen two actual full-fledged doctors. The rest were interns, residents, doctoral candidates, doctoral fellows that were not licensed
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and trained in specific trauma therapy. I was retraumatized on
many occasions. All of that is outlined in my written testimony.
I believe Paula J. Caplan was right when she said being devastated by an assault is not a mental illness. Furthermore, it has
been well documented that psychiatric diagnosis is not scientifically grounded, does not improve outcomethat is, does not reduce human sufferingand carries tremendous risks of many
kinds. Assault survivors should be offered services without the requirement they be given psychiatric labels. These can be arbitrary
and very subjective.
Further complicating matters is there in no universally accepted
ideal treatment for PTSD. Having a diagnosis of PTSD does nothing without comprehensive care.
As for the future of this problem from the military to the VA,
what I see is more of the same. Most of the chiefs of staffs were
cadets when I was raped in 1975. This year at West Point they had
to disband the rugby team for inappropriate behavior. The number
of failures this year alone is too long to list. This climate must
change. Every day, 71 more people are assaulted and 22 veterans
commit suicide and we dont know how many of those are because
of assaults and rapes.
[THE PREPARED STATEMENT OF VICTORIA SANDERS APPEARS IN
THE APPENDIX]
Mr. BENISHEK. Thank you very much, Ms. Sanders. I truly appreciate your words.
Ms. Wilken, please go ahead.
STATEMENT OF LISA WILKEN
Ms. WILKEN. Thank you. I am a United States Air Force veteran.

I was medically separated after a sexual assault, and I am currently rated 100 percent service-connected by the Department of
Veterans Affairs. I am a wife and a mother, and more importantly,
I am a military sexual trauma veteran. In my opinion, that is the
DoD and the VAs way of categorizing us as we are rape survivors
of friendly fire. And I use those terms not to make a joke of it, but
to bring it home that we were assaulted by someone who wore the
uniform as we wore and not all people wear the uniform as honorably as you do.
Thank you for giving me the opportunity to speak today. I have
struggled for many years to be proud of my service because of the
experience that I had in the military, but speaking out about this
topic makes it so that if another veteran doesnt have to suffer and
struggle with the things that I have struggled with, it is important
for me to do so. And not a day goes by that I dont deal with something that is a result of the sexual assault.
Why is PTSD from assault so long lasting? I believe the reason
for that is that it is not properly treated or dealt with at the time.
The treatment that we receive when we report an assault in the
military, it is as if we are the perpetrator. We are the ones who
are put under the microscope. And that is something that needs to
stop. It is almost as if your chain of command sets out to do some
type of emotional blackmail on you, or emotional trauma, and that
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is something that a rape survivor cant handle at that time. You
are in a closed society.
Most people dont realize how much the VA treatment facilities
mirror our military treatment facilities. And so that is one of the
big hurdles that the VA must start with, is recognizing that there
are a lot of men and women that will not come to the VA for treatment because of the experience that they had in the military or because at the time there wasnt the whistleblower protection and
they didnt report it. But now that they are older and having problems, they wont come to the VA because of their experience in the
military.
You are going to hear me speak a little bit about outside treatment facilities. We need the ability to go outside of the VA, if services are not available for us at that VA medical center, so that we
dont have to suffer in silence. We need groups at our VA medical
centers for support, and we need groups outside of VA facilities.
Most people dont realize that sexual assault is not something
that you can be treated for. It is not like a broken arm where your
arm is in a cast for 6 weeks and then you are fine. Military sexual
assault or sexual assault in general, is something that changes a
person from that point forward. It takes the opportunity of what
you could have become and changes it to what it makes you.
Why is it so important that we speak out about this topic? The
reason that it is so important that we speak out about this topic
is so that other men and women who are currently wearing the
uniform understand that they are not alone and that there are people out there that will stand up for them.
One of the things that is important to realize is in our treatment
we need better resources. And those resources can be outside of the
VA in our local communities. Right now, at our Indianapolis VA
medical center, the wait to get into see someone to treat you for
military sexual trauma is almost 2 years. If we could utilize our
local health care providers and mental health providers, I know the
men and women in Indiana would utilize that. Unfortunately, getting approval from the VA to go outside is a difficult process, and
it is not something that is done easily.
We have MST coordinators at all of our VA facilities. Unfortunately, they are generally just one person and they have other assigned duties. We need military sexual trauma coordinators at all
of our VA facilities that have a staff, that they are able to do things
more than just push the paperwork for those veterans; that they
are able to interact with that veteran and make sure that the veteran is receiving the care that they need, and if they are not, have
the ability to stand up for that veteran. Because those are the
things that we didnt get while we wore the uniform. And being
able to have those services available to us now can change peoples
lives.
Thank you for your time.
[THE PREPARED STATEMENT OF LISA WILKEN APPEARS IN THE APPENDIX]
Mr. BENISHEK. Thank you very much for your testimony.

Mr. Lewis, please proceed with your testimony.
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STATEMENT OF BRIAN LEWIS
Mr. LEWIS. Chairman Benishek, Ranking Member Brownley, distinguished Members of the Subcommittee, and Members of Congress sitting with the Subcommittee, it is a privilege and honor to
be testifying before you here today. I would like to thank my partner Andrew Beauchene, who could not be here today. Our significant others allow us to do so much, and they receive so little credit
for the time, effort, and energy that they put into us as survivors.
And I want to acknowledge that before I start.
I would also like to thank the Subcommittee for treating the
issue of military sexual trauma in a gender-inclusive way. As the
Chairman pointed out in his opening statement, about 14,000 of
the 26,000 sexual assaults on active duty are male victims. This
gender-neutral conduct places the Subcommittee further ahead
than the White House and very much ahead of the Veterans
Health Administration. Indeed, it has been my experience that the
Veterans Health Administration discriminates against male survivors of military sexual trauma solely because of their gender.
This is a practice that needs to be brought to light and stopped by
the Subcommittee.
Currently, the Veterans Health Administration operates about 24
residential treatment programs for post-traumatic stress disorder.
Only about 12 were designed specifically for the treatment of military sexual trauma. Of those 12, only one accepts male patients.
That facility, the Center for Sexual Trauma Services at VA Medical
Center Bay Pines is coeducational. Put simply, male survivors have
no single-gender residential treatment program designed specifically for military sexual trauma. I know, I tried. There was nothing
available for me in a single-gender capacity.
This made it very difficult to process the issues when I was at
VA Bay Pines. I join the American Legion in saying that the coeducational model of residential treatment programs needs to be overhauled, and quickly.
In the outpatient environment, care for male survivors of military sexual trauma can be spotty at best. While there are counselors available for us, receiving care such as peer support groups
and being allowed to speak about military sexual trauma in mixed
gender and/or mixed trauma groups, by which I mean combat
PTSD and military sexual trauma mixed together, can be very difficult for any veteran, male or female. This needs to stop. Male survivors are the equals of female survivors and need to be treated as
such by the Veterans Health Administration.
I have placed more substantive data in my written testimony
about my personal treatment at VA Bay Pines and at the Baltimore VA Medical Center, and I will leave that in there. The next
topic I would like to touch upon is the overall supervision of military sexual trauma.
The overall supervision of military sexual trauma programs within the Veterans Health Administration has been vested in the Director of Womens Mental Health, Family Services, and Military
Sexual Trauma. This oversight protocol denigrates the experience
of male survivors and reinforces the concept that the Veterans
Health Administration sees military sexual trauma as a, quote/unquote, womens issue. That is not the case. Male survivors have
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just as much right to seek and be treated at the VA as any other
survivor.
Another harmful practice is personality disorders. As this Subcommittee is well aware, personality disorders have been used,
along with adjustment disorders, bipolar disorders, and many other
forms of errant and weaponized psychiatric diagnoses to push survivors of military sexual trauma out of the military. And it has farreaching consequences. For example, survivors attending the Topeka, Kansas, facility are asked to defend their discharge and explain it on the application to enter Topeka, Kansas program. A
survivor who has been pushed out with one of these weaponized diagnoses does not want to do that.
So I strongly urge the Subcommittee Members to support H.R.
975, the Servicemember Mental Health Review Act, offered by representative Tim Walz. This legislation would give veterans like myself who have been misdiagnosed with personality disorders to
apply for potential military retirement and shift some of these costs
back to where they belong.
In conclusion, the Veterans Health Administration fundamentally fails male survivors of military sexual trauma every single
day. They have proven their inability to adequately care for us.
That is why me and several other survivors have founded Men Recovering from Military Sexual Trauma, an organization designed to
help and advocate for male survivors. We respectfully request Congress to legislate equality in practice for male survivors of military
sexual trauma.
Thank you, Mr. Chairman.
[THE PREPARED STATEMENT OF BRIAN LEWIS APPEARS IN THE APPENDIX]
Mr. BENISHEK. Thank you, Mr. Lewis, for your testimony. I truly
appreciate your efforts here.
Ms. Johnson, would you please go ahead?
STATEMENT OF TARA JOHNSON
Mr. JOHNSON. Chairman Benishek, Ranking Member Brownley,

and Members of the Subcommittee, thank you for the opportunity
to speak today. I proudly served in the Marine Corps for 10 years
and achieved the rank of Major. I am now 40 years old, and this
is the first time I have ever disclosed my experiences regarding
MST and the care I received or did not receive from DoD and the
VA.
I joined the Marine Corps because I wanted to serve my country.
My first incident of MST occurred when I was an officer candidate
and I was sexually assaulted by a senior officer. Throughout my career in the Marine Corps, I endured several more incidents of MST.
I did not disclose these experiences, as I had seen the unfair treatment of those who had reported incidents to their command.
Despite these experiences, I excelled in the Marine Corps and
lived the motto so familiar to Marines as suck it up and press on.
I spent almost 8 years in active duty. I returned as a reservist on
active duty in 2009. Again, I experienced an incident of MST. I
began to suffer from depression, anxiety, and panic attacks.
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During this period, I did find the courage to approach my command regarding these incidents. My statements were simply dismissed, and I endured even more harassment and abuse. I sought
and received medical treatment for panic attacks, medication, but
I was never asked about MST by medical personnel. I was put on
medication to relieve depression and anxiety. It got so bad I requested early release from these active duty orders because the situation was just so difficult I felt I could not endure it any longer.
This decision to leave active duty early placed me, as well as my
children, in an extreme fragile financial state for a very significant
period of time. The complete pride I have felt as a Marine in the
past is now riddled with shame, self-doubt, and distrust. In October
2010, I sought treatment from the Madison, Wisconsin VA. I received extremely limited treatment for the depression, anxiety, and
panic, and I was mainly prescribed medications. While it was evident through screenings, I had severe symptoms of PTSD, I was
never asked by a provider if I had experienced MST. So basically,
I came in, I had undergone these screenings for PTSD, but yet, I
wasnt a combat veteran, but yet no one looked at these symptoms
and these screenings and said, well, what is actually causing this?
What is happening here?
For the first time in my life I contemplated suicide, but I knew
I needed to continue to cope for the sake of my children. While the
psychiatrist I saw was helpful, it was extremely difficult for me to
receive consistent treatment at this time as I was not yet serviceconnected, and I received little to no medication monitoring. And
I sincerely feel that the medication caused even more depression
and more anxiety and was the reason I had contemplated suicide.
In December 2010, I had my comp and pen exam for mental
health. I entered this exam with the hope that the provider would
address MST and I would finally be able to receive help. The doctor
spent 20 minutes with me. He was extremely abrupt and impersonal and did not once ask me about anything related to MST. I
was not given the opportunity to disclose my experiences. He ended
our appointment very quickly, stating he was sure I would be fine,
and my hope deflated.
The next few months, as I waited for service-connection, I was
informed that because of my income the prior year, even though I
was currently unemployed, I would have to pay for any care that
I received from the VA during this time. I was not yet financially
stable and could not afford extra costs as a single mother of two
boys. I then contacted the transition patient advocate at Madison
and disclosed my MST experience. He immediately contacted the
regional office and attempt to have MST added to my claim. I was
directed by the regional office to prepare and submit a statement
that described the details of my assault and other incidents.
Though extremely difficult, I completed and submitted this statement. I was hopeful the information I provided would allow me to
receive another examination where I could address my experiences
of MST.
Despite fulfilling their requests, I was not granted another exam.
I continued to struggle my symptoms and memories as well as severe side effects from medication. Because MST was not addressed
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in any of my exams, I was told I was not able to utilize the local
vet center.
Several months later, I did receive my service-connection and
was able to meet with a provider. During intake for the PTSD program, the VA provider again did not ask about MST, but I decided
I needed to disclose my experiences. I was extremely detailed and
candid. This provider informed me that I did appear to have severe
PTSD and would really benefit from treatment. My sense of relief
quickly disappeared as she informed me the wait list for PTSD
treatment was at least 4 months long.
When I did get the opportunity to begin treatment, my provider
was only at the VA twice a week. I was a working single parent
and it was extremely difficult to schedule consistent appointments.
There were instances I would take time off work and arrive at an
appointment only to be told it was canceled. I was also made aware
that even though the hospital had canceled these appointments, my
patient record reflected I had no showed or canceled myself. This
was simply not the truth. I grew more distrustful and frustrated.
I was then informed I was non-compliant, because I felt I
couldnt participate in a therapy called prolonged exposure therapy
for fear that it would increase my symptoms, panic attacks, and affect me personally and professionally.
Throughout this period, I also received limited medical care at
the VA through the womens health program. No VA nurse or doctor ever asked me if I had experienced MST, though several of my
medical conditions have been directly correlated with MST. During
this time, I was also employed at the VA in the same program.
MST was not addressed. And though there was an MST coordinator at this hospital, I had never had the opportunity to speak
with her, and I had never witnessed any collaboration between the
womens health program manager and the MST coordinator. I attempted to speak to my program manager several times regarding
the need to address the issues of MST with our veterans, but I was
unsuccessful.
In 2012, I decided to attempt to engage in treatment at the VA
once again. I was assigned a male provider who was new to the
VA. During my first appointment, through tears and fear, I again
disclosed my experience with MST. The provider looked at me, widened his eyes, sat back in his chair and said, Well, do you really
think you were raped? I could not bring myself to return to the
VA. And it was at this time that I began to utilize my private insurance. I now pay out of pocket for all of my therapy.
Based on my experiences and those of other veterans I have
worked with and spoken with, I recommend the VA reconsider
their approach to MST screening, acknowledgment, and treatment.
The VA needs to become a safe environment where MST is acknowledged. If I had only been asked about my experiences with
MST, I would have provided full disclosure. I, like many, was never
asked.
Thank you.
[THE PREPARED STATEMENT OF TARA JOHNSON APPEARS IN THE
APPENDIX]
Mr. BENISHEK. Thank you very much for your testimony.
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Unfortunately, they called votes on the House floor. So we will

be back in session as soon as they conclude. I truly appreciate all
of your testimony, and the bravery that you all have shown to come
here and testify about these deeply personal and difficult events.
We will be in recess until I get back.
[Recess.]
Mr. BENISHEK. The Subcommittee is called to order. I am going
to yield myself 5 minutes for questions.
Frankly, the testimony that I heard from all of you today is, really, really revealing and tragic, and I know that there is bipartisan
support in the Subcommittee to make significant changes in the
way DoD and VA treat victims of sexual trauma.
I think maybe the most interestingand I heard this before from
other casesof the testimony that I heard from you, Ms. Sanders,
was the factand I think this sort of came out in all of your testimonythat you never get someone at VA, if you ever get into counseling, that is a consistent provider. I know how difficult that is
trying to talk to somebody that doesnt know your case.
Can you expand on your testimony there, Ms. Sanders, and make
us all aware how difficult it is to get a consistent provider, even
once you have gotten a provider, or has it been so bad that you
never were able to get anybody consistently?
Ms. SANDERS. When I first entered the system, there was a fantastic clinic, and they treated us very well. They went out of their
way to make sure we got the treatment we needed. But it was led
by a very dynamic person. That was dismantled, and we were left
with scraps. Ended up, I was the only person going to that clinic
and was seeing a social worker, and unfortunately she passed
away, so I was left with no care.
I moved to north of San Francisco because I had a grandchild
and I started care at the San Francisco VA because I cant drive
very far, and I have had no real care in 2 years. I asked for a fee
basis. I got a fee basis at one point. I took it to our local county.
They closed the county office the second day I was there. And it
was a facility that treated both civilians and military sexual trauma victims, and people who were coming out of jail and trying to
get off of drugs and trying to get their children back.
I have since asked again for a fee basis. I was told, you have got
a fee basis for two sessions. I was never told where to take that
fee basis. I was never told who to contact. I attempted to say, okay,
I have Medicare, can we get some movement on that? I received a
phone call. They said, go on the computer and look up caregivers
in your
Mr. BENISHEK. That was all the guidance you got?
Ms. SANDERS. Excuse me?
Mr. BENISHEK. That was all the guidance that you got?
Ms. SANDERS. I have in front of me a fee basis that I was supposed to receive from May. I never got the letter in the mail. I
called after 6 weeks because I was told, we dont know how long
it will take. And she said, oh, it is already expired. So they sent
it to me and it expired July 17th. I still have no one to take it to,
no help to find anyone to take it to. I asked if a social worker could
sit down with me and make the phone calls if they didnt want to
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do it, but I alone cannot just sit down and call every provider in
my county to find out who will take the VAs fee basis.
The one person I contacted said it would cost me $450 for the
first session and $280 for every session after that, and she had to
have the money up front, and I had to go get the money from the
VA. And then I came here.
So I am hoping that by coming here and telling you guys that
a measly two fee basis is not going to get me anywhere. No decent
provider is going to say, oh, yes, I will see you twice and then we
will wait and see how long it takes for them to get back to us. A
real provider wants to give care consistently and comprehensively,
and that cant be done with two fee basis at a time.
Mr. BENISHEK. Yeah, of course.
Ms. SANDERS. Does that answer your question?
Mr. BENISHEK. Well, yes, it gives us a feeling of what is going
on because it is just so frightening, frankly, the testimony that we
have heard here this morning. And I know that there is great bipartisan support to make this better. But, my frustration persists.
I thank you. And I am out of time.
Ms. Brownley, you have 5 minutes for questioning.
Ms. BROWNLEY. Thank you, Mr. Chair.
And again, I want to thank all four of you for being here today
and sharing your story with us. It is extremely important in terms
of our work moving forward.
I want to say, certainly as a new Member of Congress, I am a
new Member of Congress, and I just want to personally apologize
to all of you because we should have done and we need to do a
much better job in support of what has happened to you as you
have served our country. And your bravery today is to be commended, and your duty as soldiers in the military and your service
to our country, but the bravery that you have demonstrated today,
I think, is really beyond the call of duty, and I am very, very grateful for your participation.
And there is no question in my mind that there is a lot of work
that needs to be done. I mean, we need to address the culture that
takes place in the military. That needs to be fixed. We need to address the transition from leaving the service to becoming a veteran.
And then certainly, if there is trauma that takes place, then we
need to eradicate that from happening in the first place, but if
something does happen, then as a veteran who has served our
country, we need to figure out how to best provide and service all
of you to the very best of our ability and to mimic best practices
that are happening outside of the VA, and what is really happening, you know, in facilities across our country when one is sexually assaulted.
So I am not even really sure where to start on the questioning,
but I guess, you know, I certainly would like to hear your positions,
or your suggestions, I guess, vis-a-vis how we can improve. There
has been conversation about sort of case management, so that we,
if someone is sexually assaulted in the military, that we transition
them with continuity of care to make that transition as best as it
could possibly be. But I would just, you know, I offer suggestions,
really, from all four of you in terms of, as you have had your own
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experiences and knowing what the system is today, how can we improve upon it?
Mr. LEWIS. Thank you, Ranking Member Brownley.
My first suggestion is that fee basis care needs to be made available at the request of the veteran. As our testimony has demonstrated, VA is fundamentally incapable of providing care to survivors of military sexual trauma in the current environment. There
are provisions in section 1720B that allow fee basis care to be offered if it is clinically inadvisable, and that is currently the case
in a lot of VAs.
I know one VA where male survivors of military sexual trauma
are seeking care in the womens clinic. That is not best practice.
That is horrible practice. These ladies as survivors deserve a space
to be safe and to not be triggered potentially by male veterans. I,
in turn, deserve the same place to go and not haveif my perpetrator were a female, which happens a lot more often than we
would think, I deserve that same place to go and not potentially
be triggered. I also deserve to have, in essence, my manhood respected by not having to seek my care in a womans clinic.
I also deserve to have a treatment program designed specifically,
and that is an area where VA can do a lot more research. There
is very little medical literature out there, as I am sure the Chairman well knows, about male survivors of sexual trauma of any
sort, and that is an area VA can be leading research and they are
not doing it.
The other suggestion I would have is to make sure that there is
continuity of care, as the previous question suggested. Just today,
I received a phone call from my current provider. He had been out
of the office intermittently on and off due to health care problems,
but still that makes it difficult. When I returned back from Bay
Pines, their facility was to ensure that I received continuity of care.
They failed at that. I went for 2 months after leaving Bay Pines
without seeing a medical doctor or a psychologist.
What sort of system do we have where we consistently fail our
veterans? I cannot in good conscience recommend VA to any survivor of military sexual trauma at this time. Thank you, Ranking
Member.
Ms. BROWNLEY. Thank you. Has my time expired?
Mr. BENISHEK. Yes, unfortunately so.
Ms. BROWNLEY. I yield back.
Mr. BENISHEK. Dr. Wenstrup, you have 5 minutes.
Mr. WENSTRUP. Thank you, Mr. Chairman. You know, in the
Army we have an acronym, LDRSHIP: Loyalty, duty respect, selfless service, honor, integrity, and personal courage. And, you know,
that means addressing wrongs that take place, and wrongs that not
only exist in the world as a military, but wrongs that exist within
our military. And what has happened to you is literally a form of
devastating trauma.
And I know I speak for all my colleagues on this Committee that
taking care of our troops is not just a nice thing to say and not just
a nice thing to do. It is our obligation to do so. And I really appreciate your courage today, and I think it is up to us to have the
courage to change policies and attitude.
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My question to you today, and I think I know the answer from

your testimonies, but I would like to hear from you directly on this.
Do you feel that currently that you would be more comfortable getting care inside or outside of the VA? And I think you just answered that.
Mr. LEWIS. Lets all answer together. Aye.
Ms. SANDERS. Aye.
Ms. JOHNSON. Aye.
Ms. WILKEN. Aye. Receiving care outside of the VA accomplishes
a couple of things. One thing that it accomplishes, it puts us in the
hands of people who are trained to treat sexual assault victims.
Unfortunately, the VA doesnt have a protocol set up to train their
employees of how to interact with military sexual trauma veterans,
therefore a lot of times they trigger symptoms and make our PTSD
worse.
Also, with fee basis being sent outside of the VA, fee basis reimburse at Medicare rates. And so I have a fee basis card. I received
that card because I had an unnecessary surgery at our VA hospital
in Indianapolis due to a nurse looking at the wrong lab results.
And as a result of that my mental health care provider, my psychiatrist, and my GYN and primary care physician wrote consults
for me to be able to seen outside of the VA. Originally it was denied. The second decision they approved me to go outside for GYN
services, but not for any other services.
When I appealed that decision, then I was given my fee basis
card and it says all medical conditions. The difficult part in that
is finding a provider in your local area that will accept that fee
basis because there is no partnership with the VA. And so if they
are a provider that does their own billing, they dont want to see
you because they dont want to have to deal with pushing the papers to the VA or waiting for that reimbursement, or if you are a
provider and you can bill private insurance $85 for an hour session,
but you are going to get back $19 for Medicare at the reimbursement rate, would you as a treating physician take that patient on?
And so there needs to be a partnership between fee basis and our
local community, and more importantly, also with a national chain
of pharmacies. Because when we see an outside provider in your
fee basis and you are given a prescription for medication, you have
to mail that in to the VA and wait for them to mail your medications to you. A lot of times those medications need to be started immediately. You have the option of going to your local pharmacy and
paying for it yourself, but then you are uninsured and you pay the
full rate for that medication.
You can then have the VA reimburse you, but as responsible veterans, the majority dont do that. They mail it in, and they wait
for it to come back. And it seems as though the VA doesnt look
for those commonsense solutions, and that is what I would like to
ask the Committee to do today.
Mr. WENSTRUP. Thank you.
Go ahead. Please, go ahead.
Mr. JOHNSON. In speaking very briefly about my employment
and time with the womens health program, one of my primary responsibilities was to do outreach calls. And the outreach calls were
literally to get numbers for women veterans who are up-to-date on
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mammograms and Pap smears, and if they were not, the process
for them to go outside of the VA, you know, through fee basis and
through working partnerships with hospitals in more remote areas
was so simple, I was dumbfounded. But yet there is still no simple
way for someone who has experienced MST to go outside of the VA
and receive counseling and therapy and medications.
So if we are doing it in one program, that tells me that it is possible to do it for others, too.
Mr. WENSTRUP. Again, that is exactly the type of input that I
wanted to get.
Mr. LEWIS. Congressman, one thing I would like to address briefly before your time expires is the use of interns and the use of students, medical students to provide care in the VA. I know at my
home VA they are heavily dependent on medical students, and that
is simply not a good practice with survivors of such complex trauma as military sexual trauma.
There is a place for medical learning. When I was at Bay Pines,
my primary counselor there was a psychology postgrad, and I found
her when I was sitting there trying to disclose details of my trauma, sitting there clicking her tongue ring as I was talking about
my trauma. To me, that is horribly disrespectful. And another instance at my home VA in Baltimore, a psychology student was running a group and was allowing combat veterans to talk about their
trauma while not allowing MST veterans to talk about theirsit
was me and one or two othersbecause the VA focuses on combat
trauma, in her own words.
Quite honestly, there are some four- or five-letter words I could
say to that, but for the purposes of the Committee we need to be
looking at the proper use of students and residents in providing
MST care and we need to be giving a hard look at that. Thank you,
Congressman.
Mr. BENISHEK. Thank you.
The gentlewoman from New Hampshire, Ms. Kuster.
Ms. KUSTER. Thank you very much, Mr. Chair, and thank you
to all of the Members of the Committee for convening this hearing.
I was one of the Members that requested that this happen, having
spoken to veterans in my area, New Hampshire.
One message I want to convey, along with Ms. Brownley and Mr.
Wenstrup and Ms. Walorski and Ms. Kirkpatrick, is that we are recently elected, Ms. Kirkpatrick coming back, but we are new Members to Congress and so we are arriving here right at a time when
the public is very focused on this issue. And I want you to know
that we are going to work with Ms. Speier, who has been working
on this issue for a long time, and with a number of other colleagues
in both the House and the Senate.
I really appreciate the chair for holding this hearing. This is a
significant issue, and we have made a real strong commitment to
work in a bipartisan way. And I want to thank my colleague, Ms.
Walorski, for leading what was truly an extraordinary effort on
this whistleblower protection, and I want you to know that we take
that very seriously. We passed that bill 2 weeks ago 423-0 in the
House. That is the kind of support you have when we come together and find common ground. So I know that we can help you,
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and I join Ms. Brownley in apologizing to you that you havent been
heard previously.
So my question, I have been trying to jump start my education
on this by going and visiting facilities. New Hampshire is the only
State without a full service veterans hospital, but fortunately, we
share the hospital in Vermont, White River, Vermont. They have
a brand new, newly opened care center. And I hear, Mr. Lewis,
your concerns, and I want to address that. But in this case, it is
a brand new womens support center where they have listened to
victims and survivors about literally the architecture, but particularly the programming that they want. I also visited a Manchester
veterans center where they have really outstanding treatment and
provision of counseling and groups and such there.
And so I want to ask you, I respect the recommendation for care
outside of the VA, and if that is the direction we go, then that
makes sense to me, because I understand we cant bring the training up all across the country. But if you were in a position to advise us of what best practices would look like if we could get to that
place in the VA system, what is it that you would recommend be
included? And this would be either in a hospital setting, in a med
center, in a vet center setting, in a clinic setting, what are the components that you would recommend to us?
Mr. LEWIS. Congresswoman, I appreciate the question. And to
hear about the program at White River Junction, quite honestly,
almost makes me want to cry.
Ms. KUSTER. It was truly incredible, and I was given the tour by
a victim that had been a part of a task force and they had addressed a lot of the issues that you are talking about including, you
know, literally, the entrance, making sure that it is glass, that the
women can see who is coming in. The only treatment providers are
female in that entire section. And so what are some of the elements
that we could be addressing?
Mr. LEWIS. I will defer to some of the women veterans sitting
here to talk about the components of the womens veterans program, but I think that the first thing that White River Junction
would do, to bring it to your area, is to do that same thing for male
survivors. We dont deserve to have to walk through the same sea
that the women veterans have complained about and be looked at
in a demeaning tone because we are not combat veterans. We also
dont deserve to be mixed in with the women only because VA cares
that little about male survivors.
Other components that I would suggest is MST programming
needs to be conducted in mental health. As a man, if I go to womens services, they are triggered, I am certainly triggered because
I feel a lot less than a man being respected as a survivor. I would
also recommend getting away from the current practice of teaching
by the manual and hoping our objective scores go down. That is not
right. It is an experience, it did cause psychological damage, and
it deserves to be looked at holistically, not out of a manual where
you go from one method to the next, to the next.
And that takes a whole-person concept. That takes peer supporters. That takes a whole range of things. And I would be happy
at some future point to talk to you about that, and I will defer to
the lady survivors here about the womens side.
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Ms. SANDERS. I would like to see satellite clinics. My mother

lives in Kansas. They have a satellite clinic that comes. It is only
a distance of 35 miles to the hospital. But twice a month they
come, and so the people can come to that satellite clinic and get
their medications renewed or get whatever it is they need. And I
think that that model should be used for military sexual trauma.
I think that if you could say on Mondays we have a womens clinic
at this address where it is not the VA, and it is just for women,
or men, and you can rent a room, it is inexpensive that way, you
are not building a facility, we are not asking you to build us the
Taj Mahal, we are just asking you to provide us a safe space close
enough to our home that we feel comfortable in going that distance.
For me, an hour away is too far at this point. I cant make it.
The vet center in my county has one man that works there, and
he cant even answer the phone because he is so busy. He is afraid
to work with female survivors because he is afraid, because he is
a big body-building man, that they are going to be afraid. When I
came out in the newspaper we had a long discussion and he said,
I am afraid of what will happen if you come out in our local paper
and women call expecting there to be a woman here. And there
isnt.
The vet centers need to be supported, and the idea of a satellite
clinic needs to be explored, which could eliminate some of the fee
basis. If you take the trained people you have, send them to Trinity
County for Wednesdays and Humboldt County for Tuesdays and
provide the care where the people are. I was a nurse and I was
taught, you always meet the patient where they are. You do not
expect the patient to come up to wherever you are. I said in my
written testimony, at times it feels like you are saying to us, if you
get close enough, I will fix that broken leg of yours, but until you
walk over here, I cant help you.
Ms. KUSTER. Right. Thank you.
Mr. Chair, I have gone over my time.
Mr. JOHNSON. Could I add one more quick comment? While I
agree with the other witnesses here, and their suggestions, I think
it goes back to basics too. I was never asked. I was never screened.
Ms. KUSTER. Right.
Mr. JOHNSON. I was never given the opportunity or that trustbuilding period to disclose my experiences, for whatever reason. If
you cant get your foot in the door and doors keep slamming in
your face, you are either going to give up, you are going to go elsewhere, or something worse is going to happen.
So I really think we need to look at the basics, and start with
consistentI am reading testimony from, you know, others that
are going to talk today saying MST screening, MST screening. In
my experience, I didnt receive that. So if we can find a more consistent
Ms. KUSTER. Yeah, that needs to be the standard.
Mr. JOHNSON.then we can get in the door and then we can decide where the treatment is coming in. But we need to look at the
very, very beginnings of putting that first step, putting your foot
into the door of that VA hospital, the people that are supposed to
know everything and help you.
Ms. KUSTER. Thank you so much for your courage.
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And thank you, Mr. Chair, for your indulgence.

Mr. BENISHEK. The gentlewoman from Indiana, Ms. Walorski,
you have 5 minutes.
Mrs. WALORSKI. Thank you, Mr. Chairman.
And again, to you all for coming today, thank you so much. I
would like to echo what Representative Kuster was saying. We are
committed to eradicating sexual trauma in the military. And we
are new, and we are all young Members here, but our passion and
our commitment to you today is that, you know, the bravery that
you have exhibited by being here today, the courage on shining a
light in the darkness makes a difference. We get calls every day
now that we have talked about this from the time we have been
here, every day there are new people coming forward and sharing
their stories. And your stories are going out today around the country, and that is why we are thankful that you made the trek. And
just to let you know that we are standing with you and we are
fighting for you. And thank you for your service to our Nation. It
is our turn to fight for you, and you have my commitment to continue to do this until we eradicate this from our military.
Lisa, I wanted to ask you particularly because you are well informed and you have made it a mission in the State of Indiana to
find out the scope of the weaknesses, the strengths of the VA. How
would you describe, overall, in the State of Indiana, treatment for
MST victims as you pursued it, not only from your perspective, but
because you know, you have a wealth of information about how our
State runs? How would you overall say the conditions are with
treatment of MST?
Ms. WILKEN. Overall, in the State of Indiana, if I had to rate it
on a scale of 1 to 10, I would give it a 3, because they are making
an effort. We have a military sexual trauma coordinator at the VA
medical center in Indianapolis who is wonderful, but she is one
person. We need more services of what has been talked about
today, whether it is satellite clinics or using outside treatment facilities, but the issue needs to be addressed, not only on a State
level, but on a national level with you here today.
Mrs. WALORSKI. I appreciate it. And also if I could follow up on
that, Lisa. And I can just tell you the information we have heard
from here today is tragic. It is just such a tragic story. And so we
hear all these stories and we see all the data and we are listening
to you. There is such a growing need to treat victims of MST.
Why do you think, Lisa, as you have gone through this maneuvering process, what do you think the biggest issue is with the VA
being so resistant to this information, and despite the pleas from
veterans, thousands of veterans around the country?
Ms. WILKEN. I wish I could answer that and give you an answer
of why, but I cant answer that because it doesnt make any sense
to me. If the treatment is already set up in your local community
or you have avenues in your local community, but the VA doesnt
have the services available, common sense would tell you, treat the
veteran, treat the survivor, and we are not seeing that right now.
And so going out into our local communities, while the VA is developing their process, would be something that would be beneficial.
Mrs. WALORSKI. And let me ask you this. You know, our hope
iswe passed this whistleblower protection law, as you are famil-
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iar with, and you were a helpful story with that as well. With whistleblower protection, you know, hopefully being valid and signed
into law in January of 2014, and if we can move this Congress to
get those outside services and those things provided outside of VA,
do you think we will see an influx of folks reporting because they
will feel like they have a safe haven on one end in the military
from retribution and on the second side not be incumbent upon
going to the VA for services that dont exist?
Ms. WILKEN. I think you will see MST veterans and survivors
come out the woodwork. There are men and women across this
country who wore the uniform and were proud to serve, but havent
been proud of their service because of the experience they had, and
if you give them the opportunity to give them skills to deal with
years of unattended PTSD symptoms, I know these men and
women will reach out and want to help themselves and their families.
Mrs. WALORSKI. I appreciate it.
Anybody else want to crime in? We have 50 seconds.
Mr. LEWIS. Thank you, Congresswoman. You asked earlier about
treatment at VA. One of the main problems is there is simply too
few providers. I go to the Baltimore VA, and we are talking a big
city here, and there are very few MST providers that are specifically trained in this area. You have heard of all of us talk about
our MST coordinators. It is a collateral duty. At a big city VA, even
at the smallest VA, that is a full-time job. I guarantee you, we
could fill this room to overflowing with veterans who could talk
about horrible treatment at the VA, and we are giving this collateral duty to one person. That is wrong.
So lets get a lot more people in there that are trained and are
willing to provide quality care, and lets get researchers in there
that are willing to do the research, especially with male survivors.
Thank you, Congresswoman.
Mrs. WALORSKI. I appreciate it.
Thank you, Mr. Chairman.
Mr. BENISHEK. My colleague from California, Dr. Ruiz.
Mr. RUIZ. Thank you very much, Chairman.
I first want to say, thank you so much, Ms. Sanders, Ms. Wilken,
Mr. Lewis, and Ms. Johnson for having the courage to come up and
tell your story once again. And I want to say how very proud I am
that today you have given voice to so many women and men who
have suffered this atrocious experience.
It is a triple assault that many of our veterans face. One is the
trauma of war or the trauma of feeling that they could die at any
moment through an experience from war, which is PTSD related.
The second is the trauma of the MST experience. And what I am
hearing now is that we have a third incident, and that is the trauma of the lack of coordinated, sensitive, and appropriate care.
That as a physician sometimes I know that the treatment can
make things worse. And so as a physician, it is absolutely unacceptable. As a congressman, it is absolutely unacceptable. And I
know I speak on behalf of everybody on this panel, I know the
hardships that many patients face, men and women who come to
the emergency department because of sexual trauma.
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I agree that sexual trauma is a holistic illness that is not something acute that can be treated with a pill. It is not a one-time
shot. It is not a one-time treatment. It is a lifetime struggle. And
part of the illness of this is the sense of powerlessness, and part
of the treatment is to regain that power as an individual, to be empowered, to feel like you are back in that control room. And so I
appreciate it because what you are doing today is giving that empowerment to a whole lot of people around our country, and I
thank you for doing that.
A side victim in all of this is the family and relationships that
you have with your spouses, your significant other, your children,
issues of trust, issues of being able to communicate. And I know
that it is very difficult. Has the VA addressed treatment with your
significant others, your families, and your closest friends?
Ms. WILKEN. I will answer that. Not to my knowledge. I dont
know that there is any type of program set up for family members,
spouses, or children. But thank you for bringing that up. It is
something that most certainly needs to be addressed.
We all talk about it as military sexual trauma. We are all rape
survivors. No one wants to use the word rape because it brings
with it all the ugliness that rape brings into your life. It was
brought into our lives, and we brought that into our familys lives,
and our families need support. They are our biggest support network. Issues need to be addressed with our significant others and
with our children. It could be modeled after an Al-Anon program
who gives support to family members of alcoholics. We need that
support so that we have a strong support system. They need a support system also.
Intimacy issues need to be addressed. That is something that we
dont like to have to talk about, our intimacy issues that we have
with those who have stood by us and who have loved us through
this process, but it is important and they deserve that. And so if
I could ask the panel to take a look at that issue, it needs to be
done.
Mr. LEWIS. And if I could follow up on that?
Mr. RUIZ. Yes, sir.
Mr. LEWIS. A significant barrier in that is veterans who are identified as gay, lesbian, bisexual, transgender, services in that department can be very difficult. I do know the VA in St. Louis,
through the work of Terri Odom, is starting in that area, but it is
not a national trend yet and that really needs to be addressed, because there can be a lot of gender confusion, a lot of sexual confusion after a sexual trauma, and that really needs to be addressed.
And I would also like to pick up on your point about survivors
having power again. A lot of times the VA takes our power away
from us or asks us to use it in inappropriate ways. I was asked to
take a nerve block to relieve some of my chronic pain, and I was
asked to take this nerve block transrectally. Imagine a mail survivor being asked to take a nerve block with a doctor. You are in
an OB/GYN chair. Your legs are up, and you are having something
inserted through your rectum and pushed into a nerve in your
prostate to remove your pain. That is the type of pain I live with.
My psychologist would not step in knowing what that procedure
would do. That power should not have been needed to be exercised
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by me. That should have been my psychologist stepping up and

saying, no, this is contraindicated. So sometimes that power is used
in both ways.
And you are right, Congressman. You know who was there for
me? It wasnt the VA. It was not anyone at the VA. It wasnt even
the doctor that gave me the injection. It was my partner that got
me out of that building. And he gets no recognition from the VA
for that effort. And they need it badly. Thank you, Congressman.
My colleague, Dr. Roe, 5 minutes.
Mr. ROE. Yes. I thank the Chairman.
And thank you all, the entire panel, for being here today.
You know, I go back as a young military medical officer during
the Vietnam era, and I was thinking, as I was listening to the testimony, what training I had had, and I am an OB/GYN doctor, and
what training did I have going into the military as a drafted doctor
and what training did I get in the military to treat this.
And I can tell you, in the military I received none, and one of
the reasons was military sexual trauma was occurring, it didnt
start now, it has been going on, but it was not recognized. I mean,
I never heard it mentioned. And just logically thinking about it,
you knew it occurred outside the military, why in the world
wouldnt it have occurred in the military. But it was one of those,
I mean, if you just think logically about that, why all of a sudden
one day I am out in the civilian world and I get drafted and sent
in the military and the next day it is not an issue.
In todays military there are a lot more women serving. I have
been to Afghanistan with Dr. Benishek and others, and it is amazing how many women now are doing a phenomenal job in the military. And so there is that issue there. And I think what we have
to do as a scientist, you identify the problem, you identify and try
to determine what the incidence of that problem is, and then you
try to find a solution to that problem.
And I think, Ms. Sanders, you brought up somethingand I
dont think the VA has ever been equipped to do that. I look at
mywe have a VA medical center in my hometown, and it is woefully undergunned in this. I can tell you right now. There is no way
on this earth they are prepared. It doesnt mean that those folks
are not willing to do it. It just means that they are not prepared
to do it adequately right now.
I think Ms. Sanders as a nurse brought this out very, very eloquently in your testimonyor answer, I should sayis that you
want to get that chair to as close to home where you feel safe and
so forth as you possibly can. It is intimidating enough to go a doctors office or to a large medical center. I mean, I am going to have
a physical next week, and I have already got sweaty palms about
it, and I have done thousands of them. So I understand exactly
what you are saying.
I think either we take the treatment to the patient, but as Dr.
Ruiz said, you cant take the wrong treatment to the patient. You
have done them harm, not good, as Mr. Lewis pointed out. So I
think we identify the problem and then look for victims, like yourself, who have suffered military sexual trauma, and come up with
a plan of how to better treat these patients, and right now we dont
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have it. And whether it is, as Ms. Wilken says, outside the VA, if
that is where the best therapy, that is where the patient should be
able to go, where they get the best treatment.
And I guess, Ms. Johnson, I was looking at your testimony and
you have said that the treatment you received at the Madison, Wisconsin VA was extremely limited, and what did you mean by that?
Ms. JOHNSON. It had to do with the fact that I was not yet service-connected, so I was continuously told that I couldnt receive consistent treatment there until my service-connection came through.
Mr. ROE. Okay.
Ms. JOHNSON. That being said, the problem with that was that
MST was never addressed, so who knew that that was part of the
issue.
Mr. ROE. Never connected the dots.
Ms. JOHNSON. Exactly. Not through, you know, my primary care
physician when I started having GYN issues, to include emergency
room visits, not mental health. And as I said in my oral testimony,
I was not a combat veteran. So to have all of these symptoms going
on and still not be screened for MST, so that I could receive treatment and therapy while waiting for my service-connection really
put me behind, and it was really a travesty because every time I
had to go there, I built myself up for a week before saying, I am
going to tell my story, this is it, I am going to be able to do it, and
then I would be deflated. And then it would take me another week
to really come down from that experience. And, you know, it was
different providers every time I went. The most often I had ever
seen the same provider was twice.
Mr. ROE. I think you hit the nail. I stayed in the same spot for
31 years before I was elected to Congress, and I have had patients
that I had known for 20 or 25 years that finally told me something
after 25 years, and it was likeI mean, they knew me well and
knew me very well and had seen me, and maybe I delivered their
children, whatever. And it was like a load of bricks being lifted
from their back. And I think you could see their life open up in
front of them. And I didnt see that one time. I saw it multiple
times.
And as I point out to you all, I did numerous sexual trauma evaluations on patients that had been assaulted in the private sector.
And as I think back to my time and the 2 years I spent in the military, I didnt do a single one. You know it was there, but it was
just so under the carpet, nobody talked about it. I think the fact
that you all have done that have really been helpful, maybe the
most helpful thing, and I think the other things you all can do is
give us ideas about how we can help the VA be better.
And we found out how doing it not right for you individually
helps, and I suspect that your story is not that much different. Everybody is an individual, but still there is a common theme here
that I am hearing.
I yield back, Mr. Chairman. Thank you.
Mrs. Kirkpatrick.
Mrs. KIRKPATRICK. Thank you, Mr. Chairman, for holding this
hearing.
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Thank you, Ranking Member Brownley, for this opportunity to

hear from you.
And thank you for showing up and your courage to testify before
Congress. I am just so sorry for what has happened to you.
I am a former prosecutor. I have prosecuted rape cases, and I
just want to know if any of your perpetrators were ever charged.
Ms. WILKEN. My perpetrator was charged. I went through the
Article 32 hearing, which is the equivalent of a grand jury hearing,
and he was charged with five charges. Went through the rest of the
investigative process, and he was given an other than honorable
discharge in lieu of court martial.
The special prosecutor that was brought in from the 12th Air
Force to prosecute the case on Offutt Air Force Base explained to
me the night before we were headed to trial the next morning, they
called me in for another meeting, and sat me down and explained
that, Lisa, I can prove that he raped you, but the rape wasnt violent enough for him to get any real jail time. And what this gentleman was doing was giving me a message of what I was in for
the next day. He knew what I had been through, through the investigation and the Article 32 hearing, but that was his compassionate way of letting me know that we can go forward with this,
and we can prosecute him, but what they are going to do to you
in the meantime is not at all going to compare to what they do to
him.
But he would not agree to giving him an other than honorable
discharge unless I agreed to it. And I was 22 years old at the time
with no victim advocate because they didnt allow them on the base
at the time, and I agreed, because I knew what I was in for, and
if it wasnt going to result in him getting any jail time, there was
no reason to put myself through that.
So they had him processed and out of the United States Air
Force and off base within 1 week, and then I found out that he had
attempted to do the same thing at his previous base. So they put
a repeat offender out into the civilian world with no criminal history.
And so it is important that you are having this hearing today so
that victims have an opportunity to realize that people are listening now, and hopefully, we can make a change so that someone
younger than myself doesnt have to make the same mistakes that
I have made over the years trying to deal with PTSD.
Mrs. KIRKPATRICK. Thank you for sharing that with us.
And you know, Dr. Ruiz, I just want to add to your list of traumas. I think there is a fourth trauma here, and that is that these
perpetrators got away with it, and there has been no justice. And
I suggest to the Chairman and Ranking Member, maybe that is a
topic that we could have a future hearing on because, you know,
they got away with it, and that is just not right. And again, I am
so sorry.
Ms. WILKEN. And if I might, the decision, you being a former
prosecutor, the decision of which cases get prosecuted right now is
currently in the chain of command. That is something that this
Congress is hopefully going to continue to take up. The Whistleblower Act is a wonderful thing that is out there so that victims
can feel confident that if they do decide to report, that they wont
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be retaliated against. But common sense again tells us, if you cant
get a commander to prosecute rape, a crime of violence, why would
a victim have any confidence that that commander is going to protect them when they come forward? So thank you for bringing that
topic up. It is important.
Mrs. KIRKPATRICK. That is exactly my concern. Thank you very
much.
Mr. LEWIS. Ms. Kirkpatrick?
Mrs. KIRKPATRICK. I yieldgo ahead. Yeah.
Mr. LEWIS. If I might, Ms. Wilken is veryI hate to use the
wrong word here, but she has seen some measure of justice. A lot
of survivors really do not see justice at all. I know in my case, I
was threatened under the dont ask, dont tell policy, and that is
a huge concern, especially in the veteranin the male survivor
community, is that we were told, if you go forward with this, you
will be outed as a gay man, regardless if you are or not, and
pushed out of the military, or you will be given some sort of
weaponized diagnosis like personality disorder or border line adjustment or whatever.
Another aspect of your question is the current process to change
your discharge. The militarys favorite line is, if this person is dissatisfied with their discharge, tell them to go to the Board for Correction of Military Records. I am here to tell you that is a joke, and
that is really deserving of this Congress attention. Less than 10
percent of all upgrade petitions are adjudicated favorably. Imagine
the psychological damage that does to a veteran when they get
first off, they are traumatized in the military, then they have to go
back to the military and say, we were hurt, we deserve our PTSD
because these people rated us as at 100 percent and these people
gave us a general discharge. And then the military says, oh, no, we
were totally right in doing it.
That is another area that totally needs to be addressed, and that
is also a good reason to pass H.R. 1593, the STOP Act, just as
quickly as possible, is to stop some of those actions and to really
enforce the whistleblower laws, because if you go ahead, especially
in the military, you are going to be pushed out and then you are
going to be told you cant get your discharge changed. And that has
implications in the VA for receiving care. Thank you.
Mrs. KIRKPATRICK. Thank you very much. I yield back. Thank
you, Mr. Chairman.
Mr. BENISHEK. The gentlewoman from New York, Ms. Speier.
Ms. SPEIER. Actually, it is California, Mr. Chairman.
Mr. BENISHEK. California. Oh, sorry, bad advice.
Ms. SPEIER. The other coast. Mr. Chairman, thank you, and
Ranking Member Brownley, thank you as well and all of the Members for showing such a deep and committed interest in this issue.
To you survivors, you are American heroes, and we owe you a
great debt of gratitude, because you are speaking on behalf of
500,000 veterans who have been sexually assaulted, raped, in the
military. I want to ask you a series of questions so that we can get
a sense, because I think I know the answers, but I think it would
be important for all of us to go beyond the numbers.
Eighty-seven percent of victims dont report, and they dont report for a very obvious reason: Because they dont get justice. So,
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let me ask this. How many of you were raped early in your military
careers?
How many of you were under the age of 25?
How many of you were under the age of 20?
Mr. LEWIS. I was 20.
Ms. SANDERS. Twenty.
Ms. SPEIER. How many of you were raped multiple times?
Ms. SANDERS. Pardon?
Ms. SPEIER. How many of you were victims multiple times of
rape?
Ms. SANDERS. No.
Ms. SPEIER. How many of you were sexually harassed?
How many of you endured an Article 32 hearing? Now, an Article
32 hearing in the military allows the defendants attorney to question the victim about their prior sexual history. Now, we have rape
shield laws in this country that prevent that from going on in civilian society, but in Article 32 hearings they are able to raise that.
How many of your assailants were in the chain of command?
All right. This is really important because this makes the case
that if we keep it in the chain of command, the likelihood of any
victim getting the kind of fair evaluation, it is just not going to
happen.
How many of you were your assailants associated with, or friends
of, or known by someone in your chain of command? So in your
case, Ms. Wilken, you are the only person that was raped outside
your chain of command, it looks like.
How many of you were treated only by medication?
How many of you were overly treated by medication?
How long after your assaults, your rapes, were you discharged?
Mr. LEWIS. One year.
Ms. WILKEN. Two years.
Ms. SANDERS. Nine months.
Ms. JOHNSON. Ten years.
Ms. SPEIER. How many of you have a DD-214, which indicates
that you have a personality disorder, adjustment disorder, or something like that?
How many of you believe that for this issue to be dealt with appropriately in the military we have to take it out of the chain of
command?
All right. How many of you, when you entered the VA system,
were asked specifically, if you had been raped or sexually assaulted
in the military?
How many of you received one-on-one counseling?
Ms. SANDERS. What?
Ms. SPEIER. One-on-one mental health counseling in the military.
How many of you were in a sexualan MST program that was
reflective of your gender?
Ms. WILKEN. It was alsoit was a rape survivor and incest survivors group. They put us together.
Ms. SPEIER. Okay. Very briefly, if you could, speak about the violence in your rapes, because we tend to overlook that because we
focus on the numbers, and most of these rapes have a level of violence that we have no conception of.
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Ms. SANDERS. I was pushed into a room by three men. One of

the men got inside with me, he pushed me down, he tore my pants,
heyou know, there was evidence that they could have collected,
but he was given nonjudicial punishment.
Ms. SPEIER. And you were locked in that room, were you not, by
the two other
Ms. SANDERS. I was locked in that room by the outside. There
were two padlocks on the outside doors, and his two friends were
not to open it until he said so.
Ms. SPEIER. Ms. Wilken.
Ms. WILKEN. Some people might say that I am a lucky victim,
that I was asleep when the assault started, so I woke up to it happening. So there are parts of the assault that I wasnt awake for
but that were evident. And so a lot of people think that if you are
not aware of the assault, that it is not as bad, but rape itself is
a crime of violence, and to have someone put their hands on your,
or be able to put themselves inside of your body without your permission in itself is violent. And so a lot of people think that it is
not as bad if you dont know exactly what happened to you, but not
knowing sometimes makes it worse.
And to bring up the point that you talked about, about using
your sexual history against you. In my case, during the investigation, I was interviewed by the Office of Special Investigation that
does things in the United States Air Force. I was interviewed for
4 hours in an 8-by-8 room with two male OSI officers, and I had
to go through my entire sexual history from the time I lost my virginity until the night that I was assaulted, and I had to answer
questions about that at the Article 32 hearing. And so it revictimizes you.
Ms. SPEIER. So my time has expired, but Mr. Chairman. Is it all
right if the last two witnesses?
Mr. BENISHEK. There is a little time for more.
Mr. LEWIS. My perpetrator used a weapon to obtain my compliance. He used a knife. Had I resisted, I would not be here. I would
be 6 feet under, and I knew that looking in his eyes.
There is a lot of victimization that goes on physically and mentally when senior members of your chain of command come down
and say you will not file a report, official report with Naval Criminal Investigative Service. That is a victimization almost as bad as
the one. I dont remember a whole lot because my perpetrator hit
me over the head and knocked me unconscious. I have been trying
to get evaluated for head issues ever since, and VA has never done
it.
So there is physical violence and there is the violence that comes
after when your command says you are not going to do this, and
then the doctors in the military say, oh, you are fine, let me push
you a boatload of pills and send you back out to sea. Or the doctor
that we go to in the military that says, oh, you are lying about
what happened, and by the way, here is your personality disorder
and a bag of pills to last you 90 days on your way out.
I took enough pills when I was stationed at 32nd Street in San
Diego to float a ship. I often called it a shuffle, because I didnt feel
my feet could touch the floor. And that is violence as well, and I
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know you meant the physical kind, but that violence needs to be
addressed as well.
And there is no gender-sensitive care for male veterans anywhere. That is why me, and a few other survivors, are standing up
Men Recovering from Military Sexual Trauma, because men dont
have anywhere to go. We are emasculated when we have to talk
about this and we dont deserve that in this culture. Men deserve
the right to be supported, too.
Thank you, Congresswoman.
Ms. JOHNSON. My situation was as a young officer candidate, and
it was actually out in a social situation that it started. And for
many years, I did not disclose it, because it was more of a date
rape situation, and I was told afterward, you know, that I pretty
much deserved it and brought it on myself. And for whatever reason, I sincerely believe that I was given something so that I
wouldnt remember or so that I would be more compliant.
Growing up in New Jersey, being a Marine, I am not a very compliant person anyway. But I dont remember much of it. But if
someone comes too close to me or I feel that someone invades my
personal space, or I smell a certain kind of smell, I become so agitated and scared to the point where I cant function, and I feel like
I am going to throw up. And that can happen anywhere. So while
it wasnt reallyI didnt come out with bruises. I came out with
pain and I came out with invisible wounds.
When it happened years later with somebody else, it was sort of
the same situation, and I was told, well, it is not rape. But I said,
no, no, it is not rape. And so while neither incident was outright
violent, I was not physically harmed in such a way as the other
witnesses, it stillthe violence in it for me was questioning my
judgment and questioning who I was as a person and believing for
so long that it was my fault and that I couldnt tell anybody.
And how you think at 22, and how you think at 40, when you
are trying to raise two young men, really impacts the way you look
at things. And when I knew, I said would I want one of my sons
to treat a woman like that or that to ever happen? And my answer
to myself was, absolutely not. And at that point I knew that, you
know, what I had experienced, and I was still traumatized from it
and that it was wrong. So completely different situation, but longlasting effects.
Ms. SPEIER. Thank you.
Mr. CHAIRMAN. Thank you for your indulgence.
Mr. BENISHEK. I want to thank you all so very much for coming
to Washington and telling your stories. You have been very helpful
to us in trying to correct this problem. It is particularly frustrating
to me to hear these stories one after another. And while your individual experiences are unique, the challenges and barriers that you
spoke of in facing VA and DoD are very similar. I hope that the
administration officials in the audience were listening as closely as
I was to your testimony.
Thank you very much, and you are excused.
Ms. SANDERS. Thank you.
Mr. BENISHEK. I would now like to welcome our second panel to
the witness table. Joining us on the second panel is Dr. Michael
Shepherd, a physician at the Office of Health Care Inspections at
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the VA Office of the Inspector General. Dr. Shepherd is accompanied by Karen McGoff-Yost, the Associate Direction of Bay Pines
Office of Health Care Inspections. Also on our second panel is Dr.
Jonathan Farrell-Higgins, the Chief of the Stress Disorder Treatment Program at the VA Eastern Kansas Health Care System, and
Carol OBrien, Chief of the Post-Traumatic Stress Disorder Program at Bay Pines.
Welcome.
Dr. Shepherd, 5 minutes for your testimony.
STATEMENTS OF MICHAEL SHEPHERD M.D., PHYSICIAN, OFFICE OF HEALTH CARE INSPECTIONS, OFFICE OF THE INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY KAREN MCGOFF-YOST LCSW, ASSOCIATE DIRECTOR, BAY PINES OFFICE OF HEALTH CARE
INSPECTIONS, OFFICE OF THE INSPECTOR GENERAL, U.S.
DEPARTMENT OF VETERANS AFFAIRS; JONATHAN M.
FARRELL-HIGGINS, PH.D., CHIEF, STRESS DISORDER TREATMENT PROGRAM, COLMERY-ONEIL VA MEDICAL CENTER,
VA EASTERN KANSAS HEALTH CARE SYSTEM, VETERANS INTEGRATED SERVICE NETWORK 15, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS;
CAROL OBRIEN PH.D., CHIEF, POST TRAUMATIC STRESS
DISORDER PROGRAMS, BAY PINES VA HEALTHCARE SYSTEM, VETERANS INTEGRATED SERVICE NETWORK 8, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF
VETERANS AFFAIRS
STATEMENT OF MICHAEL SHEPHERD
Dr. SHEPHERD. Mr. Chairman, Ranking Member Brownley, and

Members of the Subcommittee, thank you for the opportunity to
discuss our recent IG report on residential treatment for female
veterans with MST-related mental health conditions. I am accompanied today by Ms. Karen McGoff-Yost, Associate Director in our
Bay Pines Office of Healthcare Inspections.
I first want to also thank the four veterans on the first panel for
their courage in sharing their experiences and their insights. I
want to briefly mention why we did this review and offer a few observations.
This inspection was undertaken in response to a request from
the Senate Veterans Affairs Committee. The report was intended
to describe the care of female veterans discharged during the 6month period from 14 programs listed by VA as having the ability
to treat mental health conditions related to MST. Although the request and the report specifically focused on treatment of female
veterans, I do want to acknowledge the incidence and distressing
impact on both male and female survivors.
In terms of the age range and service era of program participants, somewhat surprisingly, the average age was 44, with the 46to 50-year-old age group as the most common. Four percent of the
patients were under 25 and a quarter were OEF/OIF veterans,
with the remaining three-quarters other service era veterans. And
I think this demographic data highlights the impact across service
eras and also highlights the pressure on the system to simulta-
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neously plan for and serve the growing mental health needs of recent vets and also aging other era vets.
Second, I want to comment on the clinical complexity of patients
served by these programs. Ninety-six percent of the patients in our
review had two or more mental health diagnoses in addition to
multiple physical diagnoses. In fact, 8 percent had concomitant eating disorders. After treatment in these programs, patients tended
to return to the clinic and facility at which they received pre-program care; 22 patients were readmitted to either an acute mental
health unit or to another residential program.
For me, the real takeaway is that for these patients, effective
treatment is not a linear one-stop in an intensive program and
done solution, but rather requires a coordinated and longitudinal
effort, building the foundation of care in the outpatient setting,
having adequate coordination forward to optimize residential treatment, and then integrating treatment back to the outpatient setting to effectively build on gains achieved.
Third, largely, all but three programs treated patients from all
over the country. There was a national draw to these programs. On
site visits, though, we found that difficulty obtaining travel funding
authorization was a consistent theme. MST policy dictates care for
veterans, even those not otherwise eligible for VA services, and
that residential MST care should be available. But VAs travel beneficiary policy is restricted to veterans meeting certain eligibility
requirements and favors treatment at the nearest facility.
We found the two policies do not align. For some patients, this
lack of alignment may delay program access. We recommended the
Under Secretary review existing policy pertaining to authorization
for veterans seeking mental health MST treatment in these programs. VHA concurred, established a work group to review issues
and provide recommendations. As of the last quarterly update, the
work group was continuing its review of this issue.
Finally, on site visits, MST coordinators consistently reported
their concerns that given their direct patient care responsibilities,
they did not have time to perform their collateral MST coordinator
duties, including outreach, coordination, and tracking of patients
with positive MST screens.
In conclusion, the programs reviewed do serve clinically complex
patients who come for treatment from across the system. Ideally,
these women and men would be engaged in a coordinated, integrated, comprehensive, and longitudinal treatment effort.
Mr. Chairman, thank you again for this opportunity to testify. I
would be pleased to answer any questions that you or Members of
the Subcommittee may have.
[THE PREPARED STATEMENT OF MICHAEL SHEPHERD M.D. APPEARS
IN THE APPENDIX]
Mr. BENISHEK. Thank you, Dr. Shepherd, for your testimony.
Dr. Farrell-Higgins, you may proceed.
STATEMENT OF JONATHAN M. FARRELL-HIGGINS
Mr. FARRELL-HIGGINS. Good afternoon, Chairman Benishek,

Ranking Member Brownley, and Members of the Committee.
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The Eastern Kansas Health Care System is comprised of two

medical centers 65 miles apart, nine community-based outpatient
clinics, and is a tertiary psychiatry facility. I am the chief of the
Stress Disorder Treatment Program, a 7-week inpatient unit for
veterans with post-traumatic stress disorder and other stress-related problems. This 24-bed unit is designed to help veterans deal
more effectively with traumatic experiences that occurred during
their military service. The unit is physically located within the
medical center at Topeka.
As program chief and as one of two PTSD mentors for VISN 15,
I am pleased to share my reflections from the field concerning MST
treatment. Our Topeka program is best described as an integrated
mixed trauma model for mixed gender. We provide inpatient treatment services for male and female veterans from all branches and
all areas of service, as well as active duty military personnel.
Trauma issues addressed include those related to combat, MST,
nonsexual assault, and training incidents. The unit is designated
as a national resource Specialized Inpatient PTSD Unit, or SIPU.
The programs overarching treatment goal is to help veterans maximize their post-traumatic growth and recovery with ultimate reintegration back into families, workplaces, and communities.
Here is some key program data. In fiscal year 2013 to date, the
unit has treated 119 patients; 28, or 24 percent of these patients
self-identified at admission as MST survivor referrals. Additional,
patients self-identified after admission as having sexual trauma
issues, in addition to other presenting trauma issues. One hundred
percent of the identified MST admissions have had a PTSD primary diagnosis.
More MST admitting cohorts are already scheduled for admission
in the fourth quarter. Of the fiscal year 2013 MST referrals, 24, or
86 percent have been men, and 4, or 14 percent, have been women.
MST patients include those who served in Vietnam, Iraq, Afghanistan, and other locales.
Of our MST referrals, males heavily outweigh females, outnumber. As is common in other inpatient and residential programs,
we experience a higher percentage of MST admission no-shows and
cancellations than for other traumas. This speaks to multiple
issues, including high comorbidities, readiness issues, and travel
difficulties.
The program is staffed 24/7 by a terrific multidisciplinary treatment team. They provide multiple evidence-based psychotherapies,
gender-specific
care,
same-gender
therapists,
diverse
psychoeducational programming, complimentary alternative medicines, or CAM, such as yoga, mind flush meditation and exercise,
and medication management.
As a national resource program, MST referrals are nationwide.
A rolling admissions format is employed wherein MST referrals are
admitted in many cohort groups in order to provide for maximum
comfort and group cohesion. In fiscal year 2013, we have not encountered any aborted on-site admissions due to safety, comfort, or
acceptance concerns.
Treatment highlights include these things. First, the programs
core value of treating diverse individual works. MST is
destigmatized by virtue of side-by-side trauma treatments. MST is
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not regarded as a second class source of PTSD, but as a primary
problem in its own right.
Second, the program achieves a powerful sense of community and
acceptance of all individuals with PTSD regardless of gender and
trauma demographics. The in vivo aspect of the treatment environment is normalizing, essential to veterans recovery efforts, and facilitates reintegration into the real world.
Third, treatment outcome data supports the mixed trauma
model. Outcome data for MST patients are comparable to non-MST
patients for PTSD, anxiety, and depression symptoms.
Last, treatment gaps and challenges include these. First, active
duty personnel. Our program is 1 hour from two military installations and we receive active duty referrals for combat trauma treatment. However, referrals for MST are infrequent. Patients report
fear of stigma and concerns about career advancement. These are
worthy issues to be further addressed.
Transportation. Some MST referrals have struggled with transportation problems to our program and to other programs. One
non-VISN female veteran who could not afford transportation to
our program was eventually flown to and from our site by a volunteer veteran support organization. Beneficiary travel policy and
MST policy must work together so program access is not a problem.
Capacity. Greater understanding is needed of the multiple factors that contribute to unfilled MST beds. MST specialized programs are encouraged to share best admission practices that improve bed utilization.
And last, research. More multi-site, multiprogram research is
needed to best discern the critical treatment components that yield
the most robust treatment outcomes.
In closing, I am pleased to be part of the growing national efforts
to treat MST, and I appreciate the opportunity to appear before
you today. I am prepared to respond to any questions you may
have.
Dr. OBrien, please proceed.
STATEMENT OF CAROL OBRIEN
Ms. OBRIEN. Thank you for giving me the opportunity to discuss

the Bay Pines VA Healthcare Systems efforts to provide the very
best care to our Nations heroes, specifically those affected by military sexual trauma.
I will begin by providing a general overview of our health care
system, the fourth busiest VA health care system in the country.
The Bay Pines VA Healthcare System serves a 10-county area in
southwest Florida, includes a large medical center located in Bay
Pines and 8 outpatient clinics located in communities within our
catchment area. Our health care system includes 3,500 employees
who are dedicated to serving the more than 100,000 men and
women who come through our doors every year.
I am the section chief of the health care systems post-traumatic
stress disorder programs, which include residential and outpatient
services to treat PTSD resulting from war-related trauma and from
military sexual trauma. Our Center for Sexual Trauma Services is
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the section of the PTSD programs that specifically treats PTSD resulting from sexual assault incurred during military service.
I began treating veterans with problems related to MST in 1993
shortly after the passage of Public Law 102-805. As a result of our
experiences, a colleague and I requested and received a VHA innovative programs grant to establish the Bay Pines Residential Military Sexual Trauma Treatment Program in the year 2000. We initially had capacity for eight female veterans and subsequently expanded the program to treat an equal number of male veterans and
to provide a wide range of outpatient services. At present, we treat
approximately 100 veterans with military sexual trauma each year
through our residential program, and our outpatient services provide care to approximately 400 veterans annually.
Our CSTS team provides evidence-based psychotherapy for PTSD
as well as gender-specific treatment interventions and other therapeutic modalities to treat the unique aspects of MST-related PTSD.
Because an overarching goal of treatment is community reintegration, our residential program has a strong focus on interpersonal
skill development and recovery that is defined by the veterans
goals and values, and we incorporate concepts from therapeutic
community models of care.
The Center for Sexual Trauma Services was the first MST-specific residential PTSD program to be established within VHA. In
addition to providing excellent patient care for veterans who come
to us from across the Nation, we initiated a national clinical training program in 2001, that has been attended by hundreds of MST
clinicians from other VA facilities and from vet centers. In addition,
our program has included ambitious clinical research initiatives
since its inception and provides training for interns and residents
from many disciplines.
Our residential treatment community includes equal numbers of
men and women. Length of stay varies based on treatment needs
and goals, and the patients take responsibility for the functioning
of their residential community through mentoring and coaching
each other, identifying shared community values and related behavioral goals, and focusing on independent problem-solving and
management of difficult emotions.
We also focus on the gender-specific issues related to military
sexual trauma. Our male and female patients meet separately to
process the impact of military sexual trauma on important aspects
of life, including sexuality, perceptions of others, and interpersonal
relationships, and then come together to recognize that sexual assault affects both men and women and is not a problem of gender.
Through their relationships with each other, they begin to trust
again and they develop an eagerness to move forward with their
lives.
As we continue to work to advance the understanding of the impact of MST and to develop increasingly effective treatment models, I respectfully make the following suggestions.
We have made huge progress in the availability of evidencebased treatments for PTSD, and these treatments have demonstrated efficacy for MST-related PTSD, but we need programs to
specifically address the complex family problems, behavioral issues,
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and co-occurring disorders that are typically seen in this group of

veterans.
We need to provide treatment earlier. Most of our patients receive treatment years, and even decades after the sexual assault.
Many of our veterans tell us that the MST resulted in the loss of
their hoped-for military career.
VA and DoD need to prioritize effective early treatment interventions to preserve the quality of life and the potential contributions
of military servicemembers who experience military sexual trauma.
We need more treatment options for men. We know that for men
who are raped, the reporting rates are lower, the incidence of
PTSD is higher, functioning in relationships and work roles is more
impaired, and treatment is less effective.
Finally, we need to understand more about the causes and the
predictors of military sexual trauma. We need additional VA-DoD
collaborative research initiatives to understand the problem from
the perspectives of both the victims and the perpetrators, so that
we can design interventions relevant to the military environment
to ameliorate this problem, so that there are no more victims.
Thank you again for the chance to testify.
Mr. BENISHEK. Thank you, Dr. OBrien.
I will yield myself 5 minutes.
Dr. Shepherd, were you here for the testimony on the first
Dr. SHEPHERD. Yes, sir.
Mr. BENISHEK. It was certainly dramatic testimony. You are with
the Office of the Inspector General. Is the Inspector Generals Office doing anything about this? Are they reviewing what the VA
has been doing? It was pretty dramatic. I would think that you
would have been on this in some way.
Dr. SHEPHERD. Well, as I mentioned in my statement, we did do
a review in the last year of residential treatment for patients with
MST-related conditions. We have done a review about 2 years ago
looking at treatment for women with combat stress and
Mr. BENISHEK. It doesnt sound like you are answering that you
reviewed what the VA is doing with military sexual trauma in view
of the testimony that we had before.
Dr. SHEPHERD. Yeah.
Mr. BENISHEK. Let me ask you this. Are you aware of the number of inpatient beds there are in the VA system for inpatient
treatment of military sexual trauma, or that would have availability appropriate for MST victims, how many inpatient beds are
there in the country?
Dr. SHEPHERD. I dont know the exact number.
Mr. BENISHEK. Do any of you know that number?
Let me ask you, the doctors that are involved with clinics themselves, are your clinics always full then?
Mr. FARRELL-HIGGINS. As I mentionedthank you for the question, Mr. ChairpersonI mentioned in my remarks that we do experience some people who do not show up for treatment that is
scheduled for them on our waiting-to-be-admitted list, but the advantage of us having a rolling admissions format as we do is that
we are able to then pull people forward and fill those positions fairly quickly.
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Mr. BENISHEK. How often does somebody have to typically wait?

You mentioned that you have somebody waiting for admissionyou
have people scheduled for the fourth quarter, I thought you said.
Mr. FARRELL-HIGGINS. We do. Of course, we are in that territory.
So we keep a waiting-to-be-admitted list so folks can get their personal affairs lined up and prepared to come into a program. It
takes some doing to get family and work and so forth.
Mr. BENISHEK. How long does this typically take?
Mr. FARRELL-HIGGINS. So I would say that we are running about
a month to 40 days right now.
Mr. BENISHEK. And so what is the census in your facility today?
Mr. FARRELL-HIGGINS. It varies.
Mr. BENISHEK. Today. Right.
Mr. FARRELL-HIGGINS. It runs from 80 to 95 percent.
Mr. BENISHEK. Dr. OBrien.
Ms. OBRIEN. Again, we typically run over 85 percent occupancy
rate. The Bay Pines residential program is considered the premier
program in the country. We get probably more referrals than other
programs do. But a couple of weeks ago, we admitted a female veteran directly to our program from the inpatient psychiatry unit
with absolutely no wait.
Mr. BENISHEK. We havent heard from you, Ms. McGoff-Yost. Do
you have anything you want to add to that?
Ms. MCGOFF-YOST. Yes. Thank you, Mr. Chairman.
As far as with our review, we looked at 14 different programs,
VA facility programs, and we had to estimate the capacity because
some of the programs are womens only and some of the programs
are mixed gender.
For purposes of our review, we only looked at beds available for
women with MST, and our estimated capacity was approximately
600. We did obtain data, both while we were on our site visits, and
also, we looked at VA self-reported data that had to do with the
capacity, and we were consistently told while we were on site, that
these programs were somewhat underutilized.
The time period for which we did our review was the first two
quarters of fiscal year 2012, which would be October 1st, 2011,
through March 31st, 2012, and during that timeframe, the data
provided by VHAs Northeast Program Evaluation Center for these
particular programs reflected an occupancy rate ranging from 42
percent through 81 percent. The programs that had a higher occupancy rate included Bay Pines, Lyons, New Jersey, and Sheridan,
Wyoming.
As far as your questions about how long it takes to access the
programs, we can get you that information. We reviewed 166 medical records as part of our review, and within our report, we do
have the data stratified by facility of how long it took from the time
that a patient was referred to the program until the patient entered one of the residential programs, and it did vary considerably.
Mr. BENISHEK. Do you think that the IG going to, in view of the
testimony we had today, do you think you would entertain a plan
to try to inspect how VA is doing things? With the dramatic testimony of coordinators, shouldnt the Inspector General be involved
in that?
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Dr. SHEPHERD. I very much appreciate the testimony, and when

I return today to the office, I will begin dialogue with my superiors
about possible inspections we might do in this area.
Mr. BENISHEK. I would appreciate follow-up to the Committee.
Thank you.
Ms. MCGOFF-YOST. It is something that has been discussed.
When wehe initially looked at doing this review, we chose to look
at the residential programs. Because these programs were identified by VHA as being specialized treatment resources specific for
this population, one of the things we did consider was looking at
outpatient services, which is a little bit more challenging because
it is so broad. Because every facility is required to offer MST-related care at every facility at every CBOC, it was a challenge to
figure out to objectively measure what they were doing, and there
can be so much variability from site to site.
Mr. BENISHEK. Right.
Ms. MCGOFF-YOST. One of the things that we considered, currently VHA facilities have a screening program where they are supposed to be doing a screening. It is an electronic screening called
a clinical reminder, where it is once in a lifetime, they screen a veteran for the presence of military sexual trauma. Currently, the
clinical reminder consists of two questions to just determine if a
patient met a criteria, at which point they are supposed to be verbally prompted to see if they would like to talk to someone further.
We were told that VHA is in the process of adding a third question to the reminder that would actually document whether or not
the person would like to seek help or further assistance related to
a positive screen. One of the things that we have discussed is that
once the clinical reminder is in place, there would actually be an
objective way for us to measure how many veterans requested help.
Then we could go back and see how many got the help they asked
for and how long it took.
So we are kind of keeping an eyeball to see when that reminder
might be getting ruled out. We were told during fiscal year 2012
that it was under process. As far as we know today, it has not yet
been rolled out nationally.
Mr. BENISHEK. Thank you for your testimony.
I yield to Ms. Brownley.
Ms. BROWNLEY. Thank you, Mr. Chairman.
And thank you all for your testimony.
You know, hearing the first panel for me was disconcerting, devastating, and your response to the testimony, it didnt seem to me
that that sense of urgency really is there. I mean, we heard about
big gaps in care, long wait times, uncaring providers, employees
that didnt seem to know what the policies were, issues around
family support, gender-sensitive care, the fact that PTSD and MST
therapies were combined, the need to get access outside of the VA,
victims not being screened.
And the data that we know, in terms of the victims who are out
there and the victims, 87 percent, I think, who actually were victimized but dont come forward, it just doesnt seem thatyour testimony and the data that we know about are really, you know,
aligned here, and somehow, I think we have got to, you know, find
those nexus points so that we are doing, you know, a better job.
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So I feel like this hearing is just beginning to scratch the surface,

and we still need to drill down further on so many of these issues
to figure out how we can provide immediate service, caring service,
the right services, the best practices, and I am sort of struggling
with that.
I appreciate your testimony. I feel like it was, you know, prepared in advance, which I understand one has to do, but it didnt
feel as though it was really responding to what we heard.
So I would just like to hear from you, from all of you, really,
what some of your responses are. And I know in the case of Mr.
Lewis, who testified, and, Dr. OBrien, you know, he gets services
from your facility and, you know, if we could hear a little bit more
from you about some of his testimony and some of his experiences.
Ms. OBRIEN. Thank you. And I, like you, reacted with a great
deal of concern and compassion for the testimony of not only the
male victim, but the entire panel. And as we move forward with
this, a part of what we need to do within VA, is to talk with our
veterans, to listen to those concerns, to continue to work with them
in order to improve our programs to meet every single individual
veterans needs.
One of the things that we are doing right now in VA that I think
will be especially helpful is that we are hiring a large number of
peer technicians, peer counselors to work with our programs, and
we will have one coming to our program at Bay Pines as well. And
again, that allows us to hear the veterans perspective. And I think
the closer we get to the words of the veteran, the more we will be
able to improve and continue to improve our treatment programs.
Ms. BROWNLEY. Any other comments?
Ms. MCGOFF-YOST. I actually have a comment, Ranking Member
Brownley. When we did our review, we looked specifically at
women, at the request of the Senate VA Committee, and we looked
specifically at specialized inpatient and residential treatment programs. So in a manner of speaking, we have a skewed sample, because we looked at those patients who made it into a very specialized program, whereas I think that the veterans in the first panel
who spoke so openly and courageously about their experiences,
from what we could gather from their testimony it sounded like
only one of the four made it into one of these specialized programs.
So while we can discuss the characteristics and the patterns from
what we saw in our sample of women in our view, it may not be
reflective of the women who arent making it into these residential
treatment programs.
We did find evidence, both in the medical records, and also
through interviews and site visits, we did hear about barriers, and
many of the barriers that we heard from staff were very similar
themes to what we heard from the veterans who spoke earlier
today. We consistently heard that the MST coordinators, there is
one at each facility, that is what we found in our review, that is
what is required, however, the directive that mandates this role to
exist does not mandate the amount of FTE or time dedicated to the
role that it needs to have.
We were consistently told on-site thatmost coordinators said
that they are mapped at about 10 percent of their time to doing
MST coordination. For instance, at the Bay Pines facility, their
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MST coordinator is a very busy lady, she wears many hats. She is
a full-time clinician, she works with patients in the residential program, she is the MST coordinator, and she is also the VISN point
of contact for MST, and that is one person.
So we were told by most of them it is 10 percent. A few said it
was as few as two hours a week they are afforded to do the outreach that they need to do. And I think that when you listen to the
examples we heard from the prior panel, a lot of them echoed that,
had there been a lot more outreach and a lot more focusing up
front on coordination and reaching out to patients when they are
coming into the system, that perhaps could have ameliorated some
of the issues related to their coordination of care.
Ms. BROWNLEY. Thank you. I yield back.
Mr. BENISHEK. Thank you, Ms. Brownley.
I yield 5 minutes to Dr. Wenstrup.
Mr. WENSTRUP. Thank you, Mr. Chairman. Thank you all for
being here today.
I know it is difficult, but always necessary in everything that we
do to self-critique ourselves, and I just wonder how you would describe or rate, on a national level, your customer service as far as
those with MST and what is it that you need that is not provided
to you today to improve upon that? Anyone can take that.
Mr. FARRELL-HIGGINS. Thank you for the question, Congressman.
I believe in Topeka, our customer service is outstanding. We have
an excellent team, and the feedback that we get repeatedly, both
from veterans who have come through the program, especially from
our referral services as well, is that they are very pleased with the
care that they have received from us.
I think we can always do better. We have brought on a peer support specialist this past year to help us out. I think it has been a
very strong move for us. We are continuing to look at how we can
link in better with local community resources to help become more
linked in with things such as recreational activities. Some staff dollars would help with that, but I think we can do some improvement
there.
Anyone else care to comment?
Ms. MCGOFF-YOST. I have a comment, since both of the panelists
from VHA mentioned the peer technicians and peer counseling is
such a positive recovery movement that is being rolled out in VHA.
That is something that we noticed when we looked at the medical
records for these women with MST who are in a residential program. We did find the presence in many of the programs we looked
at, that there was peer counseling available or a peer support technician who was there. However, from what we could see in the
medical record documentation, and we were looking at veterans
who were women, we only saw one female peer support technician
who was working in these particular programs, and I believe that
was in the program in Cincinnati. And I know that VA has mandated that the residential programs need to get ready to have up
to 15 percent of their population be female. However, they have no
set threshold for what number of their peer support technicians
need to be female.
Mr. WENSTRUP. Thank you very much. And I yield back.
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Mr. BENISHEK. Ms. Kuster, 5 minutes.

Ms. KUSTER. Thank you very much, Mr. Chairman. I will be
more mindful of my time. Thank you.
Thank you so much for coming before us today and for the work
that you do. I understand that you are very committed to it. And,
Dr. OBrien, I admire you being a part of this for a long, long time.
And, Dr. Farrell-Higgins, I am impressed by the program you described. And thank you to our friends that are looking into this
deeper.
So my question, I want to focus in on a comment that you made,
Ms. McGoff-Yost, aboutyou used a phrase once in a lifetime
screening, and I guess the comment that I would have is, it is very
clear to me from our first panel that once in a lifetime screening
would not be adequate. And I think actually Dr. Roe spoke very
eloquently about this, of knowing his patients for 30 years and it
takes 25 years to have this conversation.
So what would you recommend that could be done across the
board throughout the VA to be more mindful of the challenge of
bringing this situation forward, that it is not just saying, I broke
my arm, can you fix it?
Ms. MCGOFF-YOST. I think that part of this issue has to do with
the MST coordinators and the time that they are afforded to follow
up on screenings, and also when they are working withwhen a
patient does disclose in whatever venue it is, to make sure that the
coordinator is aware and that the screening then gets put back to
being positive in the medical record.
A clinical reminder, they can be set in the electronic medical
record at certain intervals. We were told by VHA that currently
this is something that occurs once. When a person, male or female
veteran, comes into a VA medical center for enrollment, they are
screened for many different conditions. MST is one of them. There
are two questions in the screening, and as I mentioned earlier, we
were told they are in the process of adding a third question.
We would probably need to defer to VHA for more specific information about their future plans for the clinical reminder. We did
have some dialogue with VHA staff at central office about the clinical reminder and the pros and cons of having it come up more
often than annually.
We did find in our particular sample all of the veterans had been
screened. We did find that out of our 166 patients, 161 were actually veterans, three were active duty, and two were reservists. So
of the 161 for whom the clinical reminder would have been turned
on in the medical record, for seven, it was still marked negative.
And that has an impact on VA collecting data because they make
tremendous efforts to collect data on these patients. If the clinical
reminder is marked negative, then some of the data that they collect would be lost.
Ms. OBRIEN. Could I add also that, although in VA we have the
requirement to ask once to do the reminder, that is not the only
way that we reach out to our veterans to let them know about the
availability of treatment and so on. We have brochures, we have
posters, we have events for Sexual Assault Awareness Week. In
multiple modalities we reach out to our veterans to let them know
that the care is available and to encourage them to seek care.
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I had a veteran say to me the other day that he had said no to

the clinical reminder, and then he saw a poster at our facility that
we have hanging right inside the door that says it takes the
strength of a warrior to seek help, and that gave him the courage
to come to us and say, I was sexually assaulted in the military and
I hear I can get some care from you.
Ms. KUSTER. Great. My time is short, but I do want to take the
opportunity to introduce an expert from my region in New Hampshire who is here with us today at the hearing, Victoria Banyard,
Ph.D., from the University New Hampshire.
Ms. KUSTER. But with regard to your comment, Dr. Farrell-Higgins, I think the connection to the services that are available in the
community, including in academia, in programming, the issue of
sexual assault and rape is not new in our society. And one of my
biggest concerns across the board, both with regard to DoD and the
VA, is that there is this effect of a total vacuum of the military and
the Veterans Administration seemingly dealing with these issues in
a vacuum.
And so, I would encourage all of you, and certainly we will encourage the Veterans Administration and the DoD, to work with
the civilian population, because it is very unique, both with regard
to coming forward and telling the story and all the way throughout.
And so, our concern is with this multiple trauma, that we learn
best practices from people who have worked. Dr. Banyard has been
working for 20 years in this field, and I am very honored to have
her with us here today.
Thank you. And I yield back.
Mr. BENISHEK. Thank you very much.
I will yield 5 minutes to the gentlewoman from Indiana, Ms.
Walorski.
Mrs. WALORSKI. Thank you, Mr. Chairman.
And I have to agree with Ranking Member Brownley in sharing
her frustration. I feel like we are in two separate worlds. We just
heard absolutely gut-wrenching testimony from extremely courageous people whose lives have been ruined, and I am frustrated sitting on this Committee.
I have been asking questions about this issue to the VA since I
have been here with no answers. So with all due respect, Dr. Higgins, the customer service is going great? Well, maybe for those
who actually access the program. But to the people that are sitting
here representing tens of thousands of people, it isnt working and
I am just frustrated.
But I want to direct my attention to Dr. Shepherd. In the report
produced by the Office of the Inspector General, it is recommended
that, quote, The Under Secretary for Health review existing VHA
policy pertaining to authorization of travel for veterans seeking
MST-related treatment as specialized inpatient residential programs outside of the facilities where they are enrolled. The VHA
agreed with this recommendation and promised to have a recommendation completed for the Under Secretary for Health no
later than April 30, 2013. Has the VHA provided you with that
status update?
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Dr. SHEPHERD. A quarterly update, which was in May, they were

still working on it and havent come up with a list of recommendations.
Mrs. WALORSKI. And let me just interject. That is exactly what
I expected to hear, because the questions that we have been asking
in the 7 months that I have been here still fall on deaf ears; no
response, no report. When we are dealing with this issue of MST,
the reason these stories are so gut wrenching, I think, is because
we have thousands of people falling through a crack in the system
and we cant even get answers to the Congressional Committee
that is in charge of watchdogging and making sure that these people get treatment.
Dr. SHEPHERD. In fact, in the last few days, with a lot of pressing, we got a response that they recently had developed some recommendations that the Under Secretary would be reviewing in the
last few weeks. So I agree with the congresswomans comments and
I very much understand the frustration.
Mrs. WALORSKI. Did the VHA give any reason for failing to fulfill
their promise?
Dr. SHEPHERD. No, maam.
Mrs. WALORSKI. Does their failure to address the situation demonstrate their inability to provide the necessary services to MST
victims, in your estimation?
Dr. SHEPHERD. It is hard to say. Certainly we would like to see
a prompt response to the recommendation we had, and we would
like to see what they have recently proposed get implemented, because we think that will help improve access for veterans needing
these programs.
Mrs. WALORSKI. Thank you.
And, Mr. Chairman, I yield back my time.
Mr. BENISHEK. Ms. Kirkpatrick.
Mrs. KIRKPATRICK. Thank you, Mr. Chairman.
Dr. OBrien, how many of the 3,500 employees at your facility
are psychiatrists?
Ms. OBRIEN. Thank you for the question. I would need to take
that for the record and get back to you on the exact number.
Mrs. KIRKPATRICK. Can you give me a ballpark number?
Ms. OBRIEN. I can tell you that in our PTSD program itself, we
have two psychiatric ARNPs and two full-time psychiatrists, with
a position open for yet another psychiatrist.
Mrs. KIRKPATRICK. I dont have your written testimony, but I am
recalling from your testimony that you said you treat 100,000 inpatients at the facility and 400,000 outpatients, is that correct?
Ms. OBRIEN. I indicated that we have 100,000 male and female
veterans who come to our facility each year.
Mrs. KIRKPATRICK. And how many of them are seeking mental
health care?
Ms. OBRIEN. Again, I dont know the exact number. I can get
that information to you.
Mrs. KIRKPATRICK. I would appreciate that.
Dr. Higgins, can you answer those questions for me for your facility?
Mr. FARRELL-HIGGINS. Thank you for the question. I find myself
in a similar situation as Dr. OBrien. On the inpatient PTSD unit,
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we have a full-time PA and an ARNP, with a psychiatrist who supervises that work. I will have to get back to you with respect to
the total number of psychiatrists in the facility.
Mrs. KIRKPATRICK. Can you give me a ballpark?
Mr. FARRELL-HIGGINS. Let me get back to you about that.
Mrs. KIRKPATRICK. Okay.
Mrs. KIRKPATRICK. Ms. Yost, you talked a little bit about staffing
in a previous question. Do you think we have a sufficient number
of psychiatrists in the VA system to treat these issues?
Ms. MCGOFF-YOST. Under our review, we looked at the staffing
specifically of particular residential programs, so I would not be
able to comment on the adequacy of staffing for the other 140 VA
facilities as far as the availability of outpatient services. We found
that there was adequate staffing for the particular programs that
we reviewed which were residential inpatient in nature.
Mrs. KIRKPATRICK. I am really concerned about the testimony we
heard from the first panel, that they are being seen by medical students, by untrained professionals, and really would like an answer
back about whether or not we have adequate professionals within
the VA system to deal with military sexual trauma.
Mrs. KIRKPATRICK. Also, in the written testimony of one of the
first panelists, she says some women are not going to come to the
VA because of a lack of treatment or a bad experience with the VA,
and we have heard in other hearings about women being hesitant
to go to the VA. And I would just like to know from the panel, what
efforts the VA is taking right now to address that, to make it a
pleasant experience for women, someplace where they would feel
protected and welcome.
Ms. OBRIEN. Thank you. I think one of the things that VA has
done over the years is the creation of womens health centers.
Every VA facility has a women veterans program manager whose
job it is to advocate for women veterans throughout the facility.
And I will talk about the Bay Pines womens clinic. It is a separate
clinic dedicated to the health care of women veterans, and in that
clinic there are also mental health providers. So that if a woman
veteran comes to ours facility and feels uncomfortable getting care
in a general mental health clinic or another setting, they can get
virtually all of their care in the womens clinic.
Mrs. KIRKPATRICK. Dr. Shepherd, are you aware of anything that
is going on within the VA to make it user friendly for women?
Dr. SHEPHERD. I think ideally that is a question answered by the
two panelists from VA. But I can say, going back 4 or 5 years ago,
in these residential programs, there was really concern about physical safety, or that, that was more of an issue, and many of the programs did put, you know, like keypad or other type devices to try
to bolster security. I can offer that, but I really think that is probably best answered by the VA panelists.
Mrs. KIRKPATRICK. Ms. Yost, do you have any comment on that,
maybe some ideas about what could be done better?
Ms. MCGOFF-YOST. Just to echo the sentiments of Dr. Shepherd.
Our Office of Healthcare Inspections, when they do scheduled site
visits, called CAPS, at approximately 50 VA medical centers each
year, they are looking at the safety and security of the mental
health residential treatment programs. They found very high com-
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pliance with the standards pertaining to the safety and security for
women veterans in those venues as far as required alarms, door
locks, rooms and bathrooms being able to lock, CCTV at building
entrances and whatnot.
I do know that the OIG is lookingalways has a component relevant to womens health, typically in our scheduled site visits both
for medical facilities and on our CBOC reviews, so it is something
they are keeping an eye on. I cannot personally comment on the
adequacy of their efforts overall as far as being more welcoming to
women.
Mrs. KIRKPATRICK. Dr. Higgins, can you describe what is going
on in your facility with that regard?
Mr. FARRELL-HIGGINS. I would be happy to. We also have a womens health clinic where a full comprehensive range of services is
available. With respect to our unit, we do indeed have alarms on
doors, and doors can be locked at night and so forth, so to maintain
the physical security of those rooms.
I think that the message is best delivered every time we interact
with a female who comes into the VA, it is that individual contact
that makes the difference. And our staff, I know staff on my end,
is well-trained and committed to that, because we do understand
the gravity of the stories that are going to unfold before us as we
work with these women and men who have been sexually traumatized.
Mrs. KIRKPATRICK. Thank you.
And, Mr. Chairman, thank you for indulging me to exceed my
time. Thank you.
Mr. BENISHEK. Thank you very much, Ms. Kirkpatrick.
I would like to yield a couple more minutes to the Ranking Member, Ms. Brownley from California. She has an inquiry.
Ms. BROWNLEY. Thank you, Mr. Chairman. This inquiry is really
to the Office of the Inspector General, Dr. Shepherd.
We have heard today, in todays testimony, a lot, but one area
that I wanted to focus on is the transition area from DoD to the
VA for military sexual assault victims. So I know, my understanding anyway, that back in 2009 there was a DoD-VA mental
health summit, and from that summit, there was, I think, an
agreed-upon strategy coming out from the DoD and the VA, but we
really dont know anything about it and really what has happened
with that. We dont know what the strategy is, et cetera.
So I think, and I think the Chairman agrees with me, that I
would certainly like the Inspector General to look into this issue
around transition, and how the DoD and the VA are going to work
together to service our military men and women who have been
sexually assaulted and report back to us in the official capacity out
of the Office of Inspector General, and would like that to happen
and to have a report that would come back to us.
Dr. SHEPHERD. In light of all the heartfelt concerns expressed
and shared by the first panel, I personally would be honored to
work on that.
Ms. BROWNLEY. Thank you, sir.
Mr. BENISHEK. I would like to thank all of you very much for
coming to testify before us today, and you are hereby excused from
the panel.
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I would like to call up the third panel. We have from the Department of Veterans Affairs Dr. Rajiv Jain, VAs Assistant Deputy
Under Secretary for Patient Care Services. Dr. Jain is accompanied
by Dr. David Carroll, the Acting Chief Consultant for Mental
Health Services for the Office of Patient Care Services, and Dr.
Stacey Pollack, the National Mental Health Director of Program
Policy Implementation for the Mental Health Services of the Office
of Patient Care Services. That is a long title. We are also joined
by Dr. Karen Guice, who is the Principal Deputy Under Secretary
for Defense for Health Affairs.
I want to thank you all for being here today. We have your complete written statements as part of our hearing record.
Mr. BENISHEK. And given the gravity of the testimony and personal experiences that we have heard in the previous panel, I
would like to go straight to questions, if you dont mind.
You were all here for the testimony of the first panel, I take it.
To me, it is very, very frustrating to hear that, and to know there
are many out there that we havent heard today, that have the
same complaints. And I know that I have received constituent letters about how people have been sexually assaulted in the Vietnam
war, but still havent reported it to their VA contact because they
are just afraid. And they didnt reveal it until they wrote me the
letter. This testimony is just so devastating.
I know you have a statement there, but maybe, Dr. Jain, you can
tell me, what was your reaction to the earlier testimony, and what
do you think that the first thing you are going to do after this hearing to try to fix this is going to be?
Dr. JAIN. Thank you, Mr. Chairman, for the question. I think
there is no question that our testimony that we submitted, as you
said, is already somewhat dated based on the testimonies that have
been provided by the four veterans on the first panel. I think they
really present a very powerful story, and I think that they point
out that inasmuch as we in the VA have done a lot for survivors
of MST over the last few years, we also feel that there are significant gaps that have been pointed out by the panel that we need
to really look, careful look and address and see how best we can
meet the needs of all of our veterans in a sensitive manner.
Mr. BENISHEK. Wouldnt you agree that this is an emergency,
that there should be rapid action taken?
Dr. JAIN. Yes, sir, I would agree, and we would certainly go back
and take a very critical look at how we have structured services
and what can we do to address some of the gaps. And, frankly, they
made a lot of wonderful suggestions that we also would want to
consider.
Mr. BENISHEK. Do you know who would be in charge of that? Is
there someone in charge of this VA? I get confused with the principal deputy, assistant director, those type of terms. I get confused.
So is there someone that you can name that is in charge of fixing
this?
Dr. JAIN. Well, sir
Mr. BENISHEK. Is that you?
Dr. JAIN. That is in charge of the patient care services? I would
certainly be willing to take that responsibility on the behalf of the
VHA, because all of the mental health services and the MST serv-
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ices are part of the mental health services and patient care services. So I would certainly be personally willing to take that responsibility to do a careful assessment, working with our leadership on
the operations side, to make sure that we have all of the appropriatethe staffing that we need to make sure that we provide the
services in a sensitive manner.
Mr. BENISHEK. Well, you have to have some caveats in there, I
understand, Dr. Jain. But to tell you the truth, I really appreciate
your answer, the fact you are willing to sit there. And I worked at
the VA as a consultant for 20 years, and I know sometimes a
straightforward answer that you gave doesnt happen that often,
even with the caveat.
I will yield the remainder of my time and allow Ms. Brownley to
go on.
Ms. BROWNLEY. Thank you, Mr. Chair, and I certainly share your
sense of urgency here today.
Earlier in the hearing, there was some discussion about the
chain of command, and I think certainly this issue, we need to go
up the chain of command within the VA and within the DoD to
make sure that we are addressing some of these issues, and that
we are really providing the very best practices to our men and
women who have served us so bravely and have so bravely testified
in todays hearing.
I wanted to go back to some of the specifics from panel one that
were suggestions, and one is going outside of the VA for services,
to access services that may be closer to home, to access perhaps
services that are best practices if it does not exist within the VA.
And it seems to me that if we do have these gaps in care and so
forth, and we want to address this with that sense of urgency, that
perhaps one solution could be is to look at the utilization of outside
services for our men and women within their areas of which they
reside. It seems to me, if those best practices are out there and
being provided, that this may be a way in which to provide those
services in a very efficient and expeditious way. And just wanted
to hear any comments from you with that.
Dr. JAIN. Thank you, Congresswoman, for that question. Let me
start the discussion on that particular topic. I think, as you say,
our VA medical center leadership at all of the facilities have a
range of options available to them in terms of looking at how to
provide services in a timely manner. And clearly the veterans on
the panel have pointed out that fee basis care is one of the options.
I would also submit to you that we have telehealth services, and
I think that was pointed out, that we could have these clinics. As
you know, we have lots of community-based outpatient clinics. Over
the last several years, mental health has now become a component
of the primary care services that are provided at our CBOCs.
What we have done over the last few years is, we have added the
telemental health services to further expand the reach of the experts that we have at the medical centers, to make sure that higher level of expert services is available in our clinics.
But listening to the testimony of one of the veterans, it is clear
that there are some areas of gaps. There are some areas where perhaps the veteran was not able to reach a community-based outpatient clinic, where there was also a combination of mental health
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services and other types of expert services for survivors of MST

that may be available.
The issue of fee based services is certainly there and clearly, as
you say, is one of the options. The challenge that one faces, though
immediately, is that you have to look at whether there are the
right professionals available to make sure that service is available
in a timely manner. I think the veterans pointed out the challenge
of the exchange of medical record information. When the services
are provided within the VA or when we partner with HRSA, for example, or when we partner with Indian Health Services, you know,
we have done several projects now where the VA in partnership is
working with those types of agencies to make sure that we share
resources and we provide the care in a timely manner to where the
veterans are.
So I think there is a range of options, and clearly one of the options would have to be fee based services. But let me ask Dr. Carroll if he would like to add anything.
Ms. BROWNLEY. Well, I would like to go on further with another
question, if you dont mind.
Dr. JAIN. Sure. Please.
Ms. BROWNLEY. The other issue is around screening, and to me
that seems like that can just be a simple fix, to make sure across
the country that we are doing the screening. And it was very concerning to hear Ms. Johnson, who is our most recent
servicemember and veteran, who clearly was not screened. And so
we say we are screening, but yet I think from the testimony, we
can conclude that it is not a fail-safe program, that every single
man and woman are not being screened. It is something that is not
complicated, it is just a matter of making sure that we are doing
it.
I also think vis-&-vis screening that screening is something that
it is not just a one-time thing. We have to continue to sort of follow
up, and there probably needs to be other places in the process
where they are screened again so it is not a one-time thing, so that
it is more of a check and balance and more of a fail-safe system.
The other thing that has come to mind in listening to the first
panel is having advocates for these men and women that can access the system, to prioritize their needs within the system to get
the services that they need and when they need it, and can help
in the coordination, also in making sure that from every place,
wherever it may be, that they are getting what they need.
And just would ask if you could comment on any of those.
Dr. JAIN. So, Congresswoman, thank you very much for those
comments. And I fully agree with you, I think that there are many
points that our veterans made, in terms of suggestions, that we
would take to heart, and we will go back and review our current
policies and procedures to strengthen.
For example, screening, as you point out, I think there are some
things that we would need to look. I was very surprised to see that
none of the four veterans. Now, in some ways the possible explanation could be that maybe the screening was conducted a few
years earlier when the screening was not fully in place, but that
is still not a reason not to do that again.
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I think you point out a very good thing here, and I think the veterans have indicated that we need to look at our procedures for
screening, to see if there is a way we could offer some kind of another chance to have the screening done in a simpler way. So I
would fully agree with that.
I think your other point also makes sense in terms of veterans
having options available, i.e., some kind of a coach or a coordinator,
and I think we are toying with some of those ideas in our primary
care clinic, in our PACT Program. We have recently introduced the
concept of coaches or health coaches, and these are over and above
the OEF/OIF coordinators we have. As you know, the OEF/OIF coordinators help in the transition of the servicemembers coming into
our system, but they also assist in coordinating care, whether it is
coordination with other specialty clinics, or coordination between
the VA and the community. You know, a lot of our PACT teams
have these post-deployment counselors that also sort of provide a
similar kind of a role.
But I think that what we are beginning to do now is to add some
more coaches that can help to further strengthen this element of
coordination of services because of a lot of the dual care that happens in our system.
Ms. BROWNLEY. Thank you. And if the chair would allow me a
little bit more time, I would like to just ask the DoD to respond
to some of these issues as well.
Dr. GUICE. I think there is a lot that we have done recently. We
have a new DODI instruction which kind of talks about the roles
and responsibilities of everyone in the Department of Defense to
specifically address sexual assault, prevention, and response. That
was just issued in April. The services are in the process of fully implementing it. We know they are compliant with the health care
provisions in there. So we know that providers are trained, we
know that they are meeting the standard for providing 24/7 coverage, that there are SAFE kits in all of the MTFs.
So I think we have actually responded in a thoughtful way to
what we also heard from survivors in our focus groups in the Department of Defense to kind of fix some of the problems that were
articulated. We are just kind of seeing if we have solved some of
the problems certainly that were articulated for the health care
parts of it. I know we still have some outstanding issues with regards to some of the other things that you all have articulated
here.
But I just want to articulate my thanks to the first panel. It is
only through their eyes that we actually see us as we are, and that
is how we fix things. So I am very grateful to their willingness to
come forward today and help us and see things the way they see
it. That is only how we get better.
Ms. BROWNLEY. Well, thank you. Thank you for that. I think we
all walk away today, hopefully the Congress, DoD, and the VA,
walk away with a sense of urgency today that we have a lot of
work ahead of us.
Thank you, Mr. Chair. I yield back.
Mr. BENISHEK. Ms. Kirkpatrick.
Mrs. KIRKPATRICK. Our Committee has heard that a stigma exists in the military that deters active servicemembers from getting
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mental health care. One of our veteran panelists suggests that

there be a Mental Health Day where professionals are brought together so that servicemembers can seek mental health care that
day and actually see professionals. Dr. Guice, has that recommendation been explored before?
Dr. GUICE. I have actually not heard of that particular recommendation. We have done a lot in the past several years to provide embedded mental health providers, both in the deployed environment, we have embedded behavioral health specialists in our
primary care teams for the patient-centered medical home. So I
think we are doing a pretty good job of trying to penetrate and provide our behavioral health specialists where they need to be, and
so that they are not seen as something different, but they are just
part of your group. And I think that that is going to go a long way.
We actually have seen in the Department an increase in people
accessing services for mental health, which I think is a good news
story. That, I think, means that we are addressing stigma. Have
we totally fixed it? Probably not. But I think some of the maneuvers and some of the choices that we have made are actually making some inroads into it. So I am quite positive.
But I will take back the idea of a Mental Health Day and we will
see how people respond to that.
Mrs. KIRKPATRICK. I represent a very large rural district in Arizona, and we are using more and more telemedicine. And I am
finding that patients are very open to that and find it is a very
positive experience. I am just thinking that telemedicine may be a
way for some of our veterans to seek mental health treatment in
the privacy of their home without having to go to a facility.
Dr. Jain, would you address that idea?
Dr. JAIN. Thank you, Congresswoman, for that question. I think
the potential for telehealth is still, I would say, in its infancy, so
we really can take this to many different levels. I think the point
that you are making and the veterans have made, providing care
where the veterans live in that community, I think is a message
that we have taken to heart. And we have done a lot, but we need
to do a lot more.
I think that the days of asking the veterans to drive 200 miles
or 150 miles to come to the mother ship and be able to receive care,
I think has to be a passe, and we need to move on to the point
where we are able to provide more services either in our community-based outpatient clinics or potentially in their homes.
So, yes, that is certainly an area that we are looking at very actively, and we will continue to expand that.
Mrs. KIRKPATRICK. Thank you. And again thank the panelists for
being here today. And I yield back.
Mr. BENISHEK. I am going to ask just a couple more closing questions.
Dr. Guice, looking at this GAO report from January of this year,
it says we found that military health care providers do not have
a consistent understanding of their responsibilities in care of sexual assault victims.
Did the testimony of the first panel, did that affect you in your
thoughts of how things are going in the system?
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Dr. GUICE. I think the testimony of the first panel was compelling and heartwrenching. I think that the things that we have addressed in our new guidance to the field, though, will go a long way
to actually try to remedy some of the things that they articulated.
All health care providers who come in contact who have any kind
of role or responsibility for sexual assault and treating those patients are requiredrequiredto have an initial treatment and an
annual refresher course. Those that actually perform the SAFE
exam, which is the forensic examination, are required to have very
specific training to a national standard, which is the Department
of Justice.
Mr. BENISHEK. Let me just ask you one quick, short question
here. There has been some concern about people who have survived
MST and their inability to stay on active duty because there is
maybe not quite the treatment protocol to allow them to do that.
Is there some way that we are addressing that in the DoD?
Dr. GUICE. I would have to actually go back and talk to people
about that just to make sure that we have got something in place
that is directly addressing that particular question, sir.
Mr. BENISHEK. All right. I would appreciate getting back to me
about that.
Mr. BENISHEK. I want to thank you all for joining us this afternoon. I truly appreciate it. And I hope that, as I said earlier, that
the testimony of the first panel affects you all in your zeal to make
things better from every aspect of VA and DoD, because I know it
is certainly affecting us here on the Committee, and we are going
to work on improving it from our end. But I would hope that this
would inspire you to work harder in making it happen.
So with that, you are excused. Thank you.
[THE PREPARED STATEMENT OF RAJIV JAIN, M.D. APPEARS IN THE
APPENDIX]
[THE PREPARED STATEMENT OF
THE APPENDIX]
KAREN S. GUICE, M.D.
APPEARS IN
Mr. BENISHEK. I will ask unanimous consent that all Members

have 5 legislative days to revise and extend their remarks and include extraneous material.
Without objection, so ordered.
Mr. BENISHEK. I would like to once again thank all of the witnesses and the audience members for joining us here today for
these important conversations. And this hearing is hereby adjourned.
[Whereupon, at 1:45 p.m., the Subcommittee was adjourned.]
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A P P E N D I X
Prepared Statement of Hon. Julia Brownley
Good morning. I would like to thank everyone for attending todays hearing, focused on examining the care and treatment available to survivors of military sexual
trauma . The Subcommittee will also be looking at the coordination of care and services offered to the victims of MST through the Department of Veterans Affairs and
the Department of Defense.
Many MST victims who have suffered through an ordeal such as sexual assault
often times are reluctant to discuss their situation and seek help. Those that finally
gather the courage to speak up find that their story is often dismissed or treated
indifferently, unjustly becoming the victim again.
As many of you know, the Pentagon reported earlier this year that an estimated
26,000 cases of unwanted sexual contact occurred in 2012, up from 19,000 in 2011.
With only 13.5 percent of incidents reported, it is clear that we must do a better
job in both preventing and treating MST. These servicemembers and veterans often
continue to experience debilitating physical and mental symptoms from MST, which
can follow them throughout their lives.
Focusing on prevention, however, is only part of the solution. It is critical that
we do all that we can to make it easier for victims of MST to access needed benefits
and services and receive treatment. Compassion and care are a significant part of
healing those that have been sexually assaulted.
I applaud the legislative efforts of our colleagues who have introduced legislation,
H.R. 1593, the Sexual Assault Training Oversight and Prevention Act and H.R. 671,
the Ruth Moore Act. These bills seek to ensure stronger protections are in place so
that the safety and well being of our men and women in uniform is assured. We
must begin to take these important steps to end sexual assault. As a proud cosponsor of both bills, I believe we are headed in the right direction.
I was saddened to read the testimonies of our first panel. The pain and suffering
was evident in the personal stories written. I know that this is hard for all of you
and I commend you on your bravery to speak up today. We need to hear, firsthand,
the experiences of veterans who have found the system unfriendly and intimidating
so that we can make it better.
I look forward to hearing from our witnesses today. Thank you, Mr. Chairman,
and I now yield back.
f
Prepared Statement of Victoria Sanders
I paid a big price to be asked to be here today. I belong to an exclusive club. The
kind no one wants to be a lifetime member of, vacations are permitted but PTSD
will always be there. Each step along the way we have lost good people. Some have
died at the hands of their rapist before they could ever report anything. Sophie
Champoux died while on active duty of a gunshot wound to the head. She was raped
two times by the same man. He confessed went to Leavenworth was to be released
very near the time that Sophies headstone was delivered. Carri Goodwin died 5
days after being discharged. A combination of medication, given to her by the military before discharge, and alcohol killed her. I attempted suicide in 1985 just 10
years after my rape. I was lucky that attempt failed.
It took almost 20 more years of slowly increasing symptoms until a woman was
raped 15 feet from my front door and my life came close to ending again. In 2004
I talked to my mother and told her for the first time about the rape in 1975. I had
never told anyone. If they would have given me the survey about sexual assaults
in the military I would have said I was not sexually assaulted. The guilt, shame,
and self-blame would not allow me to see what I now understand more clearly. My
symptoms are still bad. The nurse training I got with my G.I. Bill helped me to be
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able to put on a brave face and go out to the world. The woman who inspired me
to become a nurse worked at the VA and on bad days she might say I could make
a lot more money someplace else but those boys need me. This was in the late 60s
early 70s the height of the Vietnam War. I expect the same from my care givers.
I was lucky at Palo Alto I had people who did things for me to keep me going.
The first appointment I got was with a PhD who stayed after hours to see me. The
woman at the vet center did me the favor to call the PhD. I was lucky. No matter
how hard it is for me I know how lucky I am. I can ask for what I need. I know
how to handle the symptoms but cant always keep them under control. I was raised
by a single mother with no high school diploma. As I tell people I was born in Georgia and we were dirt poor. We moved to Kansas and we could not even afford dirt.
I am lucky that my mother told me to go to the VA, lucky that the first person I
saw asked the right question. Tell me about your time in service. Everything fell
out of my mouth. The rape, the harassment, the custody battle, years of denial all
came to an end that day.
Again I was lucky after my fiance Alan Seidler died his family cared enough about
me to give me money every month. Homelessness was not an issue. At a certain
point I was afraid to be alone so I moved in with family friend. Dr Betty Mudock
was an 80 year old women who had Alzheimers. I needed her she needed me.
When Dr Irene Trowell Harris came to Palo Alto with a large group of Washington people I told her I was lucky that I got the care I needed when I needed.
That I was able to verbalize what other cant. That a part of me can, as I am doing
today, put on the suit of armor and go on through the battle. Later I will lick my
battle wounds and revert to isolation, fear, anxiety, flashbacks, anger, not being able
to open my mail. Not being able to be the mother I want to be the grandmother
I want to be, the sister I want to be, the daughter I want to be.
When Samantha Gonzalez said to me, tell me about your VA care. Out poured
the frustration of the gaps in care I outlined.
My medical care San Francisco VA:
2011
May 26 - SFVA ER intake
Jun 1 - SFVA intake
Jun 27 - SFVA womens clinic
July 11 - Zwelling They looked up appointment and said appointment was in the
computer for the 12th 9am. I became very upset a social worker saw me and took
me into an office he contacted Zwelling who said it says in my notes I made appointment for 11th had about 15 minutes to talk with her about finding someone
to use the two fee basis appointment. Made appointment for the 25th of July then
she called and change appointment to Aug 1 so I could attend a group meeting that
day and see her.
Aug 1 - Zwelling called me to say she was going home ill rescheduled for Aug 4
at 2pm. At this point I felt I could not continue to try to see this provider in one
month she missed appointment, failed to tell me where her office was, then changed
appointment to Aug 4 (what I was wanting her to do is help me find a provider
for the fee basis I was given). I felt that after the 20 days of changes missed opportunity and confusion I could not trust her with my mental health care. I communicated this to my primary provider.
The next thing that happened was not a missed appointment but a combination
of county budget cuts and lack of services for women in the area.
Aug 10 - signed up for Marin Services for Women
Aug 12 - attended first session of MSW
Aug 15 - attended second session of MSW around 11 am leaders come into the
room and say we have announcement the MSW outpatient service is closing in 3
weeks. I was outraged that this group claimed they had no idea until that morning
this facility was closing. So then I was left with no fee basis not even the two they
had given me and no mental health help. [Exhibit A]
Sep 12 - Dr Hasser (when arrived clerk did not know I had appointment it took
about 15 minutes to contact Dr to find out I did have appointment)
Sep 19 - Pain Clinic 4 hr appointment-these 4hour long appointments are very
difficult for a person with chronic pain.
Oct 24 - Dr Chin
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The following list are appointments with Christine Celio (Post Doctorate Fellow)
appointments made in person weekly on Fridays for either 10 or 11 am. She worked
in pain clinic. When she asked me what I was trying to gain from sessions my answer was I want to feel safe when I come here. It is a very scary place, many men,
early failures, no groups available at a time that would work for me.
Dec 9, Dec 16, Dec 30
2012
Jan 27, Feb 10, Feb 24, Mar 9, Mar 23, Mar 30, Apr 6, Apr 13, Apr 20, May 4,
Jun 1, Jun 8, Jun 15.
Jan 23 - Dr at womens clinic the clerk was a not aware had appointment again
had to check with Dr, then said oh you do have appointment
May 14 - womens clinic asked for mammogram was told not done every year but
every other year. I had a notice from Stanford where I had mammograms since 2004
telling me it was time to do my test. Dr said no, new thing done every other year.
July 25 - VASF Dr Hasser. This appointment was made by phone message left
for me by Dr Hasser. When I arrived I was told I did not have appointment Dr with
another patient. Showed my notes to clerk about phone messages left for me by Dr
Hasser. She said maybe it was not with Dr Hasser and told me there were no appointment for me in system. Left clinic 7 out of 10 angry. I was called back to the
clinic saying they would see me.
Aug 8 - VASF Dr Mesa
Aug 22 - VASF Gynecology (resident) was told by Dr only have 15 minutes
Aug 27 - VASF womens clinic
I had shoulder surgery Sept 19 outside of VA care this prevented me from being
able to access help. I had learned the year before that fee basis was not going to
happen. There are still no services in Marin and choices are gotten slimmer. A few
calls to local programs all would require fee on sliding scale basis would not even
accept fee basis if available. My mental health was declining more isolation, unable
to open mail or answer phone.
Oct 18 - Called for medication refill I left message for Dr Kerlikowske that I was
running short and needed her to reorder it so I would get what I needed.
The source of this problem come because the pharmacy will say we sent you a
months supply the 1st of October so the next should not be sent out until November
1st. The problem with this thinking is if you send me a 30 day supply and there
are 31 days in the month I will run out. I was told the only way to get the drug
sooner was to call the clinic and ask the doctor for an RX. I told them that is what
I had done and they told me she order it to be shipped on Nov 2. I asked that a
pharmacist call me to discuss.
Oct 22 - I got a call from the pharmacist my frustration was growing. I was told
the Dr had written for me to get the next shipment sent out on November 2nd, now
leaving me with 3 days without medication. I was told it was written by the doctor
that way and I would have to contact them again. I asked for a face to face meeting
with a pharmacist. Told that could not happen for a couple of weeks. So I asked
what would happen if it was a new drug for me and I needed information, it would
still be a couple of weeks. I got a call back later saying I could not have appointment
it does not meet the requirements for a face to face meeting. It was the way the
doctor ordered it. Also told that if I needed a change I would have to call clinic back.
That the doctor had made an error by not ordering it for October 31st. Then I asked
if the doctor had ordered 8000mg and it should have been 800mg would you call
me and tell me to call the clinic or would the pharmacy take care of the problem
before it got to the patient. That ordering the wrong date is just as wrong as ordering the wrong dose.
Oct 23 - got call back from pharmacy (I think Susan) said she would give this
to a supervisor.
Oct 23 - I called Patient Advocates office and never got a call back.
Oct 30 - When I received the medication the dosage was changed from 200 mg
three times a day to 300 mg two times a day. I called the pharmacy again spoke
to Debbie she said it was reviewed and changed. It was a dosing adjustment.
When I asked why the answer was shocking. They dont want to have so many pills
in the pharmacy. I asked if the 200 mg was being taken out of the stock, the answer
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was no we sent you a letter to explain. [Exhibit B] At this point I made appointment
to see Dr at womens clinic the first available appointment December 3.
Dec 3 - SFVA womens clinic made appointment to discuss the change in dose for
my pregabalin the Pharmacy made from 200mg TID (three times a day) to 300mg
BID (two times a day)
Dec 7 - received wrong dose of medication. Dr Kerlikowske ordered 200mg BID
(two times a day) Called Dr at womens clinic told them about mistake. Did not receive return phone call. [Exhibit C]
Dec 10 - Called womens clinic again, explained their actions were hurting me,
causing me to be more emotionally unbalanced because I cannot be sure that anyone
is communicating or listening to me. That I had gone to see the dr because of a
change made by pharmacy without discussing with either my doctor or myself.
Was called back later by womens clinic nurse she said she was sorry for error
and will send what I needed.
Dec 18 - called Pharmacy spoke to Ed to see when I would get the rest of the
medication. Timir from the pharmacy called me later to tell me medication was
being sent out today.
2013
Jan 28 - SFVA womens clinic to discuss the error that was made when she
changed the order that the Pharmacy had changed.
Mar 14 - SRVA intake Nicole Randall Phd fellow said no process groups available
maybe in July. No individual therapy available possible 6 month waiting list. Offered Anger management group Friday 2 pm (this is a very difficult time to drive
north on highway 101) given paper from last year listing groups that are possible
at the SRVA. On the list was the was Womens coping skills show to meet on Tuesday at 11:30
Mar 15 - anger management group- Leader Nicole Randall held in large room
where the veterans are all sitting next to each other with our backs to windows.
Group leader did little more than read the last lesson in the book. Came time for
relaxation exercise that is when I realized the chairs were much too large my feet
would not touch the floor when I sat back. I pointed this out to the group leader
when I was asked how the relaxation was. I looked for a different size chair in the
room and there were none. I am not sure who this room is outfitted for but not a
good place for me. It felt again like I was not being considered. That an average
height woman 55 cannot sit in a chair and have her feet hit the floor. This has
never happened to me before in any office I have been in, I was very confused about
why we were not able to find a nice small room where we could make eye contact
with each other and feel like we are not on display for everyone who walks into the
clinic.
Mar 22 - Anger management. Was called at the end of session by Dr Hiroto. Met
her after she invited me to a new group starting the next week. I agreed to coming
noted it on my calendar but somehow failed to get the time written down.
Mar 25 - called SRVA to confirm group time was told 11:30
Mar 26 - Arrived at SRVA checked in at desk asked where and when the group
would start. The man at the desk said they would be meeting in an office right off
the lobby at 11:30. At 11:40 went to desk to ask about the group since no one had
showed up. The lady I spoke to again said it would be 11:30 in the room off the
lobby and pointed where I had been waiting. I told her it was past 11:30 and no
one showed. She then got on the phone and asked. She then told me the group was
at 2 pm. I got very angry and told her I need to talk to someone right now or I
was going to be 10 out of 10 angry. At that point the security guard came over and
said we not going to have that in here. I assured him I would leave if I got to
a 10. Let me add I made no threat other than I was angry and needed to see a
person. A few minutes later Dr Hiroto came out and started to talk to me in the
lobby. I asked her to join me in the conference room. I told her about all the mistakes that had been made that are listed here. How frustrated I have been because
of the chronic pain from multiple sources. That just driving an hour sitting and hour
and then driving an hour would not help me. That I need help in my county within
a 10 to 15 minute drive. I am sure I did not make a good impression. I called patient advocate office to ask them to document yet another appointment that was
miss-handled.
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Mar 27 - received phone call from Megan McCarthy. Explained all of the above
briefly told her the problem is I need relevant content. Not basic skills. I need process group and individual therapy. She said these are not available long waiting list.
We discussed the idea of me using my Medicare benefits to have someone in my
community help me.
I am not sure who I spoke to but I was asked if I would take an appointment
with a doctor. The person asked me if I would come up to Santa Rosa and have
a Skype with a Doctor in San Francisco. I asked why I could not drive to San Francisco to see him there it seemed silly to drive 40 miles to Skype with someone who
is working 35 miles from me in the other direction. I was then given an appointment to see Dr Threllfall in Santa Rosa April 10 at 9 am. I asked if that was the
only time I could come. I was told that this kind of appointment was always at 9
am.
April 10 - arrived just before 9 am checked in at desk told to go to waiting area.
I waited for 45 minutes before I went back to the desk. I was told they would contact the doctor to go back and wait. About 5 minutes later I was called in to the
office. Dr Threllfall said he was sorry but he did not know he had an appointment.
{a side note here after he said that all I could think was, you work for the VA,
mental health is overwhelmed to point of no appointments available, this is not just
a problem here by VA wide and has been in the news, why would you be here getting a paycheck if you did not have appointments at 9 am on a Wednesday.}
The session was a disaster, he asked why I was there. I told him about the mix
up with appointment that the VA is not just not helping me but it is hurting me.
He left the room several time and each time returned asked another question that
I know I have answered many times and should be well documented. Things like,
how was your childhood? Do you have hallucinations? What medication are you on?
What is the biggest problem for you today? I told him anxiety due to my lack of
care and being forgotten and pushed under the rug again just like when I was
raped, not just by him today but by the system. He gave me a prescriptions. I never
took it, why should I need to be medicated when they system is failing me.
Apr 11 - received a call from Chantell asking me to make appointment with Dr
Threllfall. I told her that he gave me a pink paper to take to the front desk. I did
and they gave me an appointment card for the date and time she was trying to
make the appointment for. I told her this is really shaking my confidence if the Dr
first doesnt know he had an appointment then forgets that he made appointment
with me in his office.
I refused to see him again.
May 8 - Still in need of care I made contact with the Cheryl Wernell Women Veteran Coordinator. Explained the difficulty I was having both getting to the VA facility and the problems I have had when I go there. She said she would make attempt
to get me fee basis again. The fee basis is not useful to me unless there is a person
who will take it for payment. I explained that I was not able to call every provider
in Marin County to find one who would and I needed help with this. She said she
would ask around and call me back.
May 22 - Another call with Cheryl Wernell she gave me the news that the fee
basis for 2 visits was approved she did not know how long it would take to get it
mailed out. She gave me 2 names. I watched my mail very closely the next few
weeks finally on June 18 I had still not received the fee basis papers called Cheryl
Wernell again. She told me that the fee basis had expired but she would see if she
could get it extended. I finally got a copy in the mail on June 22nd. It was postmarked June 19th It was extended until July 17th. When I called the number I was
given one was disconnected the other called back after three phone calls in a week
and said I had to pay a fee of $450 for the 1st visit and $280 for each session and
she would not take the fee basis as payment.
Jun 18 - called to get refill on prescriptions had to call womens clinic I cannot
just call the pharmacy for a refill of pregabalin
July 1 - had not received medications so called to see why. I was told they were
never got the message. I called again on July 8 and was told first that it went out
Friday, then after checking the pharmacist said it was filled on Friday but was
being mailed on the 8th. Received on the 9th of July.
I have kept notes both on my calendar and in notebooks. I have copies to back
up everything I have said here. I am sure the medical records do not contain the
information about the mix ups and my impression of my care at the San Francisco
VA. Along the way I tried to contact the patient advocate. Many of my messages
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were not answered I received a letter from the Chief of Quality Management to
apologize for some of these events. [Exhibit D]
Summary: the act of trying to get care that meets me where I am as a patient
is not happening. The system is out of touch and things as simple as the pharmacy
emailing a doctor about a problem is not the policy. When I am told to come back
in three months cannot make appointment in person before I leave the answer is
we will send you a card to remind you to make appointment. When you get the
card in three months it takes 6 weeks after that to get an appointment. That makes
it really 4 and 1/2 months not 3. This starts the cycle all over. I was told at one
point that the Womens Clinic Doctor is only in on Monday and Thursday. The rest
of the time she does research. The system is set up to fail. The failures of the caregivers I have had in the last 2 years is unacceptable. If you look at appointments
that I made over the phone or were made for me out of twenty one, seven of them
had major problems that triggered me and made my life more difficult. That is 1/
3 of my appointments causing problems not making them better. The only successful
time was when I was the 17 appointments every Friday in the pain clinic. When
I made the appointment face to face for the next week. This was just a temporary
help not long term supportive and not a trauma processing time. It was with a doctorate fellow (in training) and her time was done there. Continuity of care cannot
be given by student that leave after a few months. In mental health care it takes
time to trust both the care giver and people you meet while getting care in a group
setting.
Everything that has occurred from my first visit when I was told the patients
park in the overflow and take a bus from there. (I am not getting on a shuttle bus
with a bunch of men). My question why dont the employees park there? To quote
the phone message you get when you call where we put veterans first. If you put
them first there would be parking for them and the employees would take a shuttle
bus. To the pharmacy policy to have the patient correct doctor/pharmacy miscalculations. No groups No individual therapy. No fee basis. Where we put veterans first?
It seems the veteran is last, and women veterans dont even make the list. Called
Mister, having to wade through a sea of men for every appointment. The first appointment I had at the womens clinic there were only 4 chairs 3 of them taken by
men, yes 3 out of 4 chairs filled with men inside the womens clinic. I am not last
I am not even on the list
One constant idea that I find unable to rectify is the physician says it is a mental
health issue, the psychologist, or psychiatrist say it is in your body. I have to remind
them both that I cant take off my head when I walk into the Dr for medical care
and leave my body behind when I walk into mental health care. The concept of a
whole body thereby a holistic approach is out the window. Everyone has a specialty
and you can only talk about the one problem. I went to a specialist, well specialist
in training and was told very clearly that I was only allowed 15 minutes for an
exam. When the doctors at the VA spend their time supervising students we are
paying them to teach not give care. A veteran sees a student the supervising Dr
will look at the notes signs off and never looks at the patient. The students do not
know how to put appointments into the computer. Student care is not giving the
veteran the best. Things like acupuncture and chiropractic care are either offered
at the VA or fee basis are given for these things. I have seen Osteopaths for over
20 years on a nearly monthly basis. I know without asking that fee basis would
never be considered for that care. It is very helpful to me and calms both the tension in my body and mind. I am lucky I have other insurance that takes care of
me. Not all veterans are as lucky as I am.
Another problem is the idea that you must get help for substance abuse before
you get help for being raped. The substance abuse is to kill the pain. You want them
to give up the pain killer before they get help for the problem which they are killing
the pain. It would be like saying. I will fix your broken leg if you walk over here
close enough.
The entire VA application process feels like a dance. You have to ask for things
a certain way, on certain forms, asking for certain forms. The military and the VA
have access to all those files so it felt like I was playing guess what we have and
guess form it is on, guess how you have to ask for it. This is the reason the backlog
exists. If a trained professional sat down with the records and the veteran it could
be a simpler process. The way that files disappear or pages get taken out of medical
records makes the job harder for the Veteran and anyone helping them find ways
to prove claims. It should not take an act of a congressperson to get files about
criminal actions or medical visits while on active duty. When I saw my file at the
C&P I was finally given after over 3 years it was 2 feet high.
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The collection of information process can include things like in my case. I was unable to access any of the medical records from the time I was a dependent of active
duty. There was no way for me to request these records without his social security
number. Almost 10 years of my medical history was lost. The critical years just after
my rape. I was lucky that the Criminal Investment report was still available. It took
two letters to Congressman Honda to get these files that proved my claim. Even
then the 1st C&P gave me a rating of 50%. My counselor wrote a letter as soon
as she saw it and said the rater was wrong. That my symptoms were more severe,
more often, and unrelenting. Even though I put on a brave face all the symptoms
of PTSD plague me. Hyper arousal, depression, fear, avoiding everything even fun
things. Flashbacks where I feel trapped in the room again with man who raped me,
I can see his face and smell the smell of old tents. Isolation from people I love like
my son and daughter, granddaughter, mother, sisters, not being able to maintain
an intimate relationship. I have been married three times and find now I dont want
anyone to invade the safe space. The emotional roller coaster of feelings never knowing if in an hour something someone says will cause me to become angry. When a
system fails it takes me back to the place where the commanders had me in a room
telling me they knew what was best.
A suggestion I would like to put forth is the idea of Mental Health days while
on active duty. Where a combination of tests and talking to mental health professionals. Most of the people affected by PTSD are young and too proud to ask for
help. The stigma of needing mental help would be removed because everyone does
it. Early signs of traumatic brain injury, depression, sexual assaults, and battle
PTSD are difficult to diagnose without a trained professional. The tests can be made
that will show signs of all the problems that plague our active duty military people.
The talking can help unit cohesion instead of picking on the ones who seem troubled
the unit can get behind the person in need. You do not have to wait until someone
is suicidal to help. Just like you dont send someone into battle without body armor
and a gun. Sending young people in harms way without mental health care is reckless. We know better now so we need to do better. Getting to the patient sooner
improves the outcomes. There is no disease that I know of that will get better by
ignoring the obvious problems. Natural disasters, bombing, mass shooting when
these happen trained mental health people are sent in to the patients as soon as
possible. It has shown that to improve symptoms of PTSD in all age groups.
Enclosures: Exhibits AD
f
Prepared Statement of Lisa A. Wilken
I am a USAF Veteran. I was medically separated from the USAF after a sexual
assault and am currently rated 100% Service Connected Disabled by the DVA. I am
a wife of almost 18 years to my wonderful husband, Robert. We have been blessed
with two sons, Joel, 12 and Benjamin, 3. I do Veteran Advocacy as a volunteer.
Thank you for giving me the opportunity to speak with you. I am a USAF Veteran
and I am rated 100% Service Connected and I am a MST Veteran. I have struggled
for many years to be proud of my service because of my experience, but by speaking
out about my experience I hope to make a difference so that another young person
in uniform wont feel the way I did for so long. I was 22 years old when I was raped.
I am 42 now and a wife and mother of two sons. Not a day passes that I dont deal
with something related to the assault.
Why is it so long lasting? I believe due to it not being treated properly from the
time of the assault compounded the problem and lack of services by DOD magnifies
the problem and by the time the VA receives us we are already behind in our recovery. Studies show that women are at a higher risk for PTSD due to trauma if their
experience was severe or life threatening, were sexually assaulted, were injured, reacted severely at the time or experienced stressful events after the event or if there
isnt a good social support network. MST Veterans have had all of those things on
top of their assault.
Study us while we are in treatment. Studies are needed, but treatment needs to
come with those studies.
We need groups at VAMCs and outside facilities. You will hear me bring up using
our civilian medical professionals a lot. Some women are not going to come to the
VA because of lack of treatment or a bad experience with the VA. Most people who
have never been in the military dont realize how much the VA system mirrors it.
That can be a negative when trying to get a MST Veteran to come in for treatment.
There are programs for treatment through the VA, but there are not many and they
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are 6 weeks long. What mother can leave their family and would an employer tolerate it? What about shorter, more intensive therapy weekends that give MST Veterans the tools they need to deal with the results of years of unattended PTSD.
There are things that need attention in most of their lives that are a result of their
PTSD due to MST and some of them dont make the connection or realize that it
can be better if they have the tools. Some have no support network and that is
something that is crucial. To have someone to talk to about things you cant talk
about with your spouse can save lives. Events could be held through each VAMC
and coordinated with local heath care providers. Using outside health care providers
I believe would be a great asset to getting more women in for treatment and have
a higher success rate as a local provider may not trigger a trust issue that the
VAMC may pose to a MST Veteran. I believe if you open up treatment for MST Veterans to go outside of the VA you will see a larger number of Veterans apply for
those services.
Protocols need to be developed for MST Veterans and follow up to ensure that
VAMC employees understand PTSD due to MST and are aware of the Veterans
they are giving care to and following VAMC standards. I hear from many women
of how their MST symptoms are overlooked or even ignored while in VAMCs on
other wards, but also when inpatient on psychiatric units. Group therapy requirements for MST Veterans need to be looked at. If you dont participate in group, you
are seen as not cooperative; when it is just that you are not going to talk in an open
group. Sleeping in a room with a stranger can be a problem. Some MST Veterans
still sleep with the light or the TV or some sort of distraction mechanism to get to
sleep. To be required to sleep with a stranger in your room, even of the same sex,
can sometimes trigger other PTSD symptoms. Nightly checks of rooms that are done
can trigger an MST Veteran. These are a few examples of issues that arise due to
VAMC employees not being trained or recognizing MST Veteran issues.
As always, more GYN services need to be available at each VAMC, but here again
is an area that our local medical community should be utilized.
Therapy for family and spouses is needed to help them to understand why they
see some of the things they do and understand what is happening. Someone for family members to ask questions of other than their parents who are struggling with
getting the answers right. Kids see and know more than any of us realize and sometimes when it is realized, it is too late and damage is done. My 12 year old son Joel
has seen his mother many times upset or angry for reasons he is too young to understand fully.
Spouses need a support network also. Some may need more than others, but it
takes a strong person to put up with PTSD from MST. There is no reasoning with
PTSD. No matter how much love you give it, sometimes it wont let an MST Veteran
love you back. Intimacy issues need to be addressed. It is an important part of marriage and is affected either physically or emotionally.
MST coordinators at VAMC need help. I am not sure if there is one at each facility, but I do know some have other duties. Our MST Coordinator, Laura Malone,
is wonderful, but we need help for her. She is one lady and is overworked and under
recognized for what all she does and for how many MST Veterans she helps and
their families.
I cant stress enough how utilizing our local medical communities could be the answer to help the VA deal with the much needed addition of more treatment for
MST. As always, money will be a big factor, but if the problem is going to be address, money will be spent on adding services at VAMCs or utilizing our civilian
medical community and their expertise. It may also serve a dual role and get more
people informed about issues facing our men and women who volunteer to serve in
our all voluntary forces.
Thank you for your time.
Lisa A. Wilken
f
Prepared Statement of Brian Lewis
Chairman Benishek, Ranking Member Brownley, and Distinguished Members of

this Subcommittee;
It is a privilege and honor to be the first male survivor of military sexual trauma
to testify before the Subcommittee about this issue. I would like to thank my partner Andy who could not be here today. I want to make it clear that I am not here
representing the gay and/or lesbian community or their issues. I am here as a veteran who was raped while I was active duty. Our significant others allow us to do
so much and receive so little credit for their sacrifices. I would also like to thank
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the subcommittee for treating the issue of military sexual trauma in a gender inclusive way. This places the subcommittee farther ahead than the White House, and
very much ahead of the Veterans Health Administration. Indeed, the VHA discriminates against male survivors of military sexual trauma because of their gender in
a multitude of ways and this is a practice that needs to be brought to light and
stopped by this committee.
I was raped while serving aboard the USS FRANK CABLE (AS40). I was discharged a year later after a Navy psychiatrist determined I was suffering from a
Personality Disorder. After moving home and almost committing suicide multiple
times, I turned to the Veterans Health Administration for assistance with my posttraumatic stress disorder. It was almost 6 years before I received PTSD specific
care.
Residential Care
Currently the Veterans Health Administration operates about twenty-four residential treatment programs for posttraumatic stress disorder. Only about twelve are
designed specifically for the treatment of military sexual trauma. Of the twelve designed specifically for victims of sexual trauma, only one accepts male patients. That
facility, the Center for Sexual Trauma Services at VAMC Bay Pines, is coeducational. Put simply, male survivors have no single gender residential program designed specifically for survivors of military sexual trauma. A complete listing is attached as Exhibit A to my written testimony. The Veterans Health Administration
should not officially sanction gender discrimination.
Information on these programs is very hard to obtain. Three days before this
hearing, I used the PTSD Locator on the National Center for PTSDs webpage to
find programs treating exclusively military sexual trauma. I used Bay Pines PTSD
program as a baseline because I knew where it was and its mission. I was not able
to access a separate listing for programs dealing exclusively with military sexual
trauma. In fact, when I clicked on the state of Florida, the Bay Pines program is
listed as a Womens Trauma Recovery Program (Inpatient). 1 For a male survivor,
knowing his services are received through a womens program is very demoralizing
and discriminatory. More often than not, there is no printed listing available as to
what programs specifically serve military sexual trauma survivors. For veterans
without Internet access, a printed listing may be the only hope they have of accessing residential care for their military sexual trauma. We strongly recommend that
each Military Sexual Trauma Coordinator be required to keep hard copies of a list
promulgated by the Veterans Health Administration as to what programs are available to treat military sexual trauma.
I attended the Bay Pines VA Center for Sexual Trauma Services residential program in June 2009. I attended this program because it was and is the only residential program specific to military sexual trauma that male survivors can access in
the Veterans Health Administration. Unfortunately, upon arrival I discovered the
program was co-educational. This presented many barriers to effective treatment in
that program. I witnessed men and women engaging in romantic liaisons during
their participation in the program. These emotional entanglements proved to be a
distraction to many survivors who were in the program with me at the time. I personally was uncomfortable sharing the details of my trauma in the same group
where women were present. I can only imagine the damage which would be caused
by requiring a male survivor whose perpetrator was a woman to attend an integrated program. Upon discharge from this program, they failed to ensure a mental
health provider was following me. This caused me significant setbacks because I had
to wait almost two months to be seen after returning to Baltimore and became suicidal during the time I was waiting for care.
Outpatient Care
In the outpatient environment, I have received less than stellar care. Until this
year, the Baltimore Division of the VA Maryland Health Care System did not have
an outpatient group for male MST survivors. This same VA hospital has had a
group for female survivors for several years. When I asked about joining the female
MST group, I was denied for no other reason than I was a man. I was forced into
mixed trauma groups. These groups permitted me no opportunity to discuss my personal trauma. I also felt stigmatized by the combat veterans there. In one mixed
trauma group, the facilitator allowed the combat veterans to bring up their trauma
because the VA focuses on combat issues in her words.
The Veterans Health Administration has very few resources outside the residential treatment setting for male survivors of military sexual trauma. Outpatient
1 http://www.va.gov/directory/guide/statePTSD.cfm?State=FL
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groups are common for female survivors of military sexual trauma. However, very
few groups are available for male survivors. I consistently hear from male survivors
seeking peer support groups. The groups that male survivors can attend are more
often than not a more general PTSD group where combat veterans are mixed with
sexual trauma survivors. In these general groups, generally no sharing of the reason
behind the PTSD is permitted. This marginalizes male survivors by forcing them to
maintain their silence about their experience.
Overall Supervision
The overall supervision of military sexual trauma programs within the Veterans
Health Administration is vested in the Director of Womens Mental Health, Family
Services, and Military Sexual Trauma. This oversight denigrates the experience of
male survivors and reinforces the concept that military sexual trauma is a womens
issue. We strongly urge that military sexual trauma be created as an independent
directorate within the Veterans Health Administration.
Within the VHA, an overwhelming majority of Military Sexual Trauma Coordinators are women. Especially in the case of men who are assaulted by women, this
presents an often-insurmountable barrier to care. We recommend that there be both
a male and female MST coordinator in each facility.
Research and Training
More research needs to be conducted by the Veterans Health Administration concerning male military sexual trauma. Currently there is very little literature available on successfully treating male survivors of adult sexual assault.
The current sequester mandated by the Budget Control Act is harming our veterans in an indirect way through the training budget. Direct care providers are finding it difficult to attend training necessary to keep current on the latest information
available in treating survivors.
Personality Disorders
I urge the Subcommittee members to support H.R. 975, the Servicemember Mental Health Review Act, offered by Rep. Tim Walz (DMN 1). This legislation would
give veterans, like myself, who have been misdiagnosed with personality disorders
the opportunity to apply for a potential military retirement from the Department
of Defense. Utilizing TRICARE for military sexual trauma related care could remove
some of the cost of providing that care from the Veterans Health Administration,
which is currently estimated at $872 million.
This diagnosis made it hard for me to receive VHA care at first. This diagnosis
creates a stigma around the survivor as a condition that predates service. I have
even heard survivors tell me they have been denied military sexual trauma related
services at the DC VA Medical Center because of their erroneous personality disorder diagnosis. In fact, the Topeka, Kansas Stress Disorder Treatment Program requires veterans to furnish a copy of their DD214 in order to access treatment and
explain on their application why they received a less than fully honorable service
characterization. This application is attached as Exhibit B to my testimony. With
these facts in mind, I fear for what kind of reception I will receive at the Minneapolis VA Medical Center when I move there. Will I be denied MST services there
because of an erroneous medical diagnosis designed to save the military money?
Conclusion
In the last few years I have done much to better my life. I graduated in May 2013,
from Stevenson University with a Bachelor of Science degree in Paralegal Studies.
My masters thesis on military sexual trauma is under consideration for publication
in Stevenson Universitys Forensic Journal. I will graduate in December with my
Master of Science degree in Forensic Studies. I will apply to attend Hamline University School of Law in Saint Paul, Minnesota, next year. I help administrate
MenThriving.org, an online community designed to help men heal from the wounds
of sexual trauma whenever received. I am an Advocacy Committee member with
Protect our Defenders, an organization dedicated to transformational change in the
militarys handling of sexual assault. I am the President of Men Recovering from
Military Sexual Trauma, a group dedicated to advocating for and raising awareness
of male survivors of military sexual trauma. Unfortunately, these accomplishments
are not the result of treatment provided by the Veterans Health Administration.
This progress is the result of finding nonprofits dedicated to helping survivors in
general, building resources to address the lack of current credible resources available for male survivors, and finding other survivors to help support me as I struggle, and finding a partner who has stayed by my side regardless of all the hurt I
have caused.
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The Veterans Health Administration fundamentally fails male survivors of military sexual trauma every single day. They have proven their inability to adequately
care for us. We respectfully request Congress to legislate equality in practice for
male survivors of military sexual trauma.
f
Prepared Statement of Tara Johnson
Chairman Benishek, Ranking Member Brownley, and members of the Subcommittee, I am honored and grateful to have the opportunity to speak to you today
regarding my experiences with Military Sexual Trauma and care and treatment
from the Department of Veterans Affairs. I proudly served in the United States Marine Corps for ten years and achieved the rank of Major. While no longer in the
Marine Corps, I am now employed as an Army Wounded Warrior Advocate, serving
severely wounded Army veterans and families. It is not my intent to discredit the
Marine Corps and the Department of Veterans Affairs. It is my goal to bring awareness to critical areas that require improvement, in order to better serve our Veteran
population.
While in college, I decided I would be honored to serve my country. I decided on
the United States Marine Corps because it was, I believed, the most challenging and
the best branch of service. I experienced my first incident of Military Sexual Trauma as an Officer Candidate. This incident was a sexual assault by a senior Officer.
Throughout my career in the Marine Corps, I endured several more incidents of
MST and witnessed other Marines suffer from incidents of MST. These incidents included assaults, attempted assaults, abuse and harassment. I did not disclose my
experiences, as I had seen the unfair treatment of those who had disclosed incidents
to their commands. Despite these incidents, I excelled in the Marine Corps and lived
the motto so familiar to Marines of suck it up and press on.
I spent almost 8 years on Active Duty and returned after my children were born,
to serve as a Reservist on Active Duty in 2009 to work with severely wounded Marine Veterans and their families. I again experienced incidents of MST, and began
suffering depression, anxiety, panic attacks, increasing self -doubt and disgust with
the situation. During this period of Active Duty, I did find the courage to approach
my command regarding these incidents. It was not a positive experience for me to
say the least. My statements were dismissed by my chain of command. Because I
had approached my command, and nothing was done, I endured more harassment
and abuse. During this period I was also in the midst of a divorce from another active duty Marine. I endured incidents of harassment and abuse from him as well
as his counterparts who shared my work space and some who were in my direct
chain of command. I sought and received medical treatment for panic attacks, but
was never asked about MST by medical personnel. I was put on daily medication
to relieve depression and anxiety. I requested early release from my Active Duty orders because the situation became so difficult, I truly felt I could no longer endure
and was discharged from the Marine Corps in August 2010. The request to terminate my orders early, prior to obtaining full time employment and VA Care and
Compensation placed me, as well as my children in an extremely fragile financial
and emotional state for a significant amount of time, however I could not tolerate
the continuous feeling of being belittled and victimized. I felt I had to protect myself, as well as my children, as they deserved a consistent, loving mother who was
not afraid to go to work and did not suffer episodes of panic in their presence. I
have since been offered opportunities to return to Active-Duty and though I respect
the Marine Corps, I am no longer able to return due to these experiences. The complete pride I have felt as a Marine in the past is now riddled with shame, self-doubt,
distrust and financial stress and uncertainty.
In October 2010, I sought treatment from the Madison, Wisconsin VA Medical
Center. I was able to receive extremely limited treatment for depression, anxiety
and panic. Treatment mainly consisted of prescribing medications. I dutifully completed the PTSD questionnaire at each appointment, and while it was evident I suffered from severe symptoms of PTSD, I was never asked by a provider if I had experienced MST. While I truly understand that the VAs focus is on our OEF/OIF Combat Veterans, and do not want to minimize their need for treatment, I believe someone should have asked me, based on my lack of recent combat deployments and my
symptoms. I pride myself in being a very strong woman, and when I was not asked
about MST, I did not feel it was appropriate to reveal this information. I was also
put on different medications throughout the next few months, some of which actually increased my depression. For the first time in my life I contemplated suicide,
but knew I needed to continue to cope for the sake of my children. I did disclose
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that I had thoughts of suicide to my psychiatrist, but did also assure her that I did
not have an actual plan. While this psychiatrist was responsive and helpful, it was
extremely difficult for me to receive consistent treatment at this time, as I was not
yet service connected, and received little to no medication monitoring.
In December 2010, I had my Compensation and Pension Exam for Mental Health.
I entered this exam with hope that someone would ask about MST and I would finally be relieved of the secret I had held for so long, and then receive help. I was
examined by a male psychologist. The doctor spent twenty minutes with me. He
was extremely abrupt and impersonal, and did not once ask me about anything related to MST. Again, I did not feel this was a safe environment to disclose my experiences. He ended our appointment very quickly, stating he was going out of town
for the weekend, stating he was sure I would be fine. My hope deflated. I recall
sitting in my car almost an hour in the parking lot, before I felt I could even drive.
This appointment set the precedent for what I felt I could and should say to the
VA.
I was not able to receive counseling throughout the next few months, as I was
waiting for my service connection. I was informed that I would have to pay for any
care I did receive from the VA during this interim period, and I was not yet financially stable and could not afford extra costs. I did finally contact the Transition Patient Advocate at Madison and disclosed my MST experience. He immediately took
action, and attempted to contact the Regional Office to have MST added to my
claim. The Regional Office directed me to prepare and submit a statement that described the details of my assault and other MST incidents. Though extremely difficult, I completed and submitted this statement to the Milwaukee Regional Office.
I became hopeful that I would be able to receive another examination where I could
disclose my experiences, but despite fulfilling their request, I was not granted another exam. I continued to struggle with symptoms and memories as well as side
effects from medications. Because MST was not addressed in any of my exams, I
was not able to utilize the local Vet Center. I even spoke with a local Vet Center
provider regarding our military experiences. I did mention that I was enrolled at
the VA, but was having a difficult time obtaining appointments. The provider then
said Well, you are not a combat veteran, or a victim of MST so you cannot come
to the Vet Center. I remember feeling very discouraged that she had just assumed
I had no experience with MST, and if she said that to me, then how many others
had she said this to? I would have entered treatment outside of the VA, but I did
not have private health insurance at this time.
I was able to meet with a provider months later in Spring 2011, after I became
service connected. My appointment was an intake for the PTSD Program. I was not
asked about MST by the provider, but finally disclosed that I believed I had experienced MST. I was extremely detailed and candid with this provider for over an hour,
in hopes I would receive treatment. When this appointment concluded, the provider
informed me that I did appear to have severe PTSD and would benefit from treatment. As she said that, I felt a weight had been taking off my shoulders, and relief
that I would get help. I was then informed the wait list for consistent PTSD treatment was four months. I remember feeling completely deflated, that I had opened
up and would have to wait for treatment.
I was afforded the opportunity to meet with a part time provider for counseling
at this time. This provider was only there twice a week. I was a single parent and
worked part time, so it was extremely difficult to schedule consistent appointments.
I was not afforded any alternatives by the VA. There were several instances where
I would take time off work and arrive at an appointment only to be told it had been
cancelled, even though I had not received a cancellation call from VA. I was also
made aware that even though the hospital had cancelled these appointments, my
Patient Record reflected I had no-showed or cancelled myself. This was simply not
the truth, and I grew more distrustful and frustrated. I was also told I should engage in Prolonged Exposure Therapy. I explained to the provider that I was afraid
to do this type of therapy, as I was concerned it would increase my symptoms and
impact my ability as a mother and at my job if I was having increased panic attacks. I was subsequently informed I was non-compliant. I stopped seeking treatment at the VA following this experience.
During this period, I had also received limited primary care at the VA, through
the Womens Health program. I was treated for simple medical issues as well as
gynecological care. No provider ever asked if I had experienced MST, though several
of my conditions have been directly correlated with MST. It was during this period
that I was also employed at the VA, in the Womens Health Program. The primary
focus of this program appeared to be the monthly number of women Veterans who
had mammograms and pap smears. I was given the mission to ensure we met our
numbers for completed mammograms and pap smears as if the survival of this pro-
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gram was dependent upon those statistics. There was no mention of MST, and
though there was a MST Program Manager at this hospital I had never spoken with
her, nor had I ever seen the Womens Health Program and the MST Program collaborate in any way. This lack of awareness further proved to me that MST continued to be shameful and was not to be acknowledged. I attempted to speak with the
program manager several times regarding the need to address the issue of MST
with our woman veterans, but was unsuccessful.
I obtained full time employment in June 2011, serving severely injured Veterans
and their families. I began to feel stronger and more confident each day, despite
lack of real PTSD/MST Treatment. In spring 2012, I attempted to engage in treatment at the VA once again. I was assigned to a male provider, who was new to this
particular VA. During my first appointment, through tears and fear, I disclosed my
first experience regarding MST. I informed this provider that I believed I had been
sexually assaulted. The provider looked at me, widened his eyes and asked, Well,
do you really think you were raped? I could not bring myself to return to him or
the VA and it was at this time I began to utilize my private insurance to receive
therapy. I now pay out of pocket to receive care.
Based on my experiences, and those of other women Veterans I have spoken with,
I recommend the VA reconsider their approach to MST screening, acknowledgement
and treatment. The VA needs to strive to be a safe environment where MST is acknowledged. If I had been asked about my experiences with MST, I would have been
relieved to speak of my experiences, but I was not asked. MST should also be consistently addressed, as PTSD is, so that Veterans who require more time to build
trust with VA Providers, have the opportunity to do so, before they disclose their
experiences. It is my opinion that VA providers should be experienced and or educated in military culture, especially for women. Veterans should be afforded greater
access to care and flexibility in scheduling and receiving care. Veterans deserve the
ability to advocate on their own behalf regarding types of therapy, as what may
work for some, does not work for all.
MST needs to be acknowledged and addressed in the primary care setting as well.
There are direct correlations between certain medical conditions and MST, such as
Fibromyalgia, GYN issues, headaches, fatigue, substance abuse and eating disorders. When a Veteran presents with a specific physical symptom or clusters of
symptoms providers must be ready to assess, identify and acknowledge the possibility of MST, and initiate screening.
My experiences with MST were extremely difficult to acknowledge. I was in denial
for many years. I witnessed many other women endure various incidents while in
the military. It became the way it was. Experiences such as this have the ability
to change the way even a very strong person perceives themselves. It creates self
-doubt and distrust not just strangers, but people who say they are here to help.
When I had appointments at the VA where MST was not addressed and/or acknowledged, I felt victimized and belittled again. MST has lifelong effects, and is truly
an invisible wound. Just recently, I had difficulty completing annual Sexual Harassment and Prevention training, required by my employer. During this instruction we
were shown a YouTube video of a young soldier who had a similar MST experience. For the remainder of that day, I was agitated and anxious which affected my
ability to serve other Veterans. As I stated earlier, I am a strong woman and I am
still surprised when I am affected like this.
MST has become part of my life and part of the woman and mother I am today.
While I never expected the VA to take care of me completely, that is ultimately my
responsibility, I yearned for validation in a safe environment. I did not get this. I
am not here today for me. I am here for those who are not ready to tell their stories
and those who have not been given the opportunity to tell their stories. I am here
for those who have survived MST and those who will experience MST. MST does
not just affect individual Veterans; it affects their families, children and our society
as a whole. I am not able to get back time I have lost with my children due to severe side effects from medications, panic attacks or traveling to appointments that
had been cancelled. It is my hope to prevent another Veteran from losing that precious time. I thank you for your time and I am grateful for the opportunity to tell
of my experiences, in hopes it will improve the care that other Veterans receive from
the VA.
f
Prepared Statement of Michael L. Shepherd, M.D.
Mr. Chairman, Ranking Member Brownley, and Members of the Subcommittee,

thank you for the opportunity to discuss the Office of Inspector General report, In-
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patient and Residential Programs for Female Veterans with Mental Health Conditions Related to Military Sexual Trauma (December 2012), and the care and treatment available to survivors of military sexual trauma (MST). I am accompanied
today by Ms. Karen McGoff-Yost, Associate Director, Bay Pines Office of Healthcare
Inspections.
BACKGROUND
The Veterans Health Administration (VHA) estimates that approximately one in
every five female veterans enrolled in VHA responded yes when screened for MST.
MST is not a diagnosis in itself. It is an experience that is associated with patterns
of psychological and/or physical symptoms. MST is a predictor of psychological distress and is associated with several mental health (MH) diagnoses, most frequently
Post-Traumatic Stress Disorder (PTSD). Research on the effects of trauma has
found that the experience of rape can be equal to or greater than other stressors,
including combat exposure, in the risk of developing PTSD. MST has also been
linked to an increased likelihood of diagnoses of anxiety disorders, depressive disorders, eating disorders, bipolar disorder, substance use disorders, and personality
disorders.
Not everyone experiencing MST will have the same response. Some individuals
who have been victims of traumatic experiences, including MST, develop few symptoms. Others develop severe and complex chronic physical and MH issues. Because
the experience of MST may result in a range of physical and psychological symptoms, treatment related to MST may occur in a variety of clinical settings depending
on the individuals needs.
VHA requires that veterans and eligible individuals have access to residential or
inpatient programs that are able to provide specialized MST-related MH care, when
clinically needed, for conditions resulting from MST. Residential programs (also
known as MH Residential Rehabilitation Treatment Programs) generally offer more
intensive treatment than typical outpatient MH programs.
In response to a request from the United States Senate Committee on Veterans
Affairs, we reviewed 14 inpatient/residential programs from a list compiled by
VHAs MST Support Team that identified themselves as having expertise with
MST and/or sexual trauma more generally and the ability to provide treatment targeting these issues in a residential or inpatient setting. Because the request was
specific to services available to women veterans who experienced military sexual
trauma, the scope of our inspection focused on the care provided to a cohort of female veterans prior to, during, and after discharge from these programs. While male
veterans were not within the scope of our review, we want to take this opportunity
to acknowledge the incidence and distressing impact of military sexual trauma on
both female and male survivors.
We reviewed the electronic health records (EHR) of 166 female veterans with a
history of MST who were discharged from these programs during the 6-month period between October 1, 2011, and March 31, 2012. Patients were included if they
met the eligibility criteria for MST-related care as defined by VHA Directive 2010
033, MST Programming. As a result, we included five women who were not veterans; three women who were active-duty military; and two who had served in the
Reserves but were otherwise ineligible for VHA care. We also visited eight program
sites representing a mix of geographic regions, facility sizes and complexities, and
urban and rural locations.
Inspection objectives were to describe the nature of services provided to these veterans, the characteristics of these veterans, the characteristics of providers, and geographic referral patterns and factors influencing access. We also assessed compliance with VHA requirements pertaining to MST care.
The programs highlighted in this inspection represent a higher intensity of care
provision than utilized by patients with a history of MST who seek only outpatient
treatment. While not covering the entire population of female veterans who have experienced MST, the review provides valuable insights into the clinical complexity,
access, and care issues impacting veterans with MST.
INSPECTION RESULTS
Patient Age and Service Era
Patients ranged in age from 23 to 65 years with an average age of 44 years old.
The most common age range was 46 to 50 years. Slightly less than 4 percent of participants were 25 years old or younger and 4 percent were between 61 and 65 years
old. In terms of service era, 38 percent of patients served in the post-Vietnam era,
27 percent each in the Persian Gulf War and Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) service eras, and 6 percent during the Vietnam era. Among the 44 OEF/OIF/OND-era patients, ages
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ranged from 23 to 51 years with an average age of 34. These patients represent veterans who served in the military during the OEF/OIF/OND-era whether or not they
were deployed. A few had also served in prior eras but for purposes of the review,
patients were categorized by their most recent era of service.
Mental Health Diagnoses
The patients in our review were clinically complex and most had multiple mental
health diagnoses. PTSD, depression, and alcohol/substance use or dependence were
the most common diagnoses. Ninety-six percent of patients had a diagnosis of PTSD,
63 percent had been diagnosed with a depressive disorder, and 70 percent had an
alcohol or substance use disorder. Approximately 27 percent of patients also had a
diagnosis of borderline personality disorder, further adding to the complexity of clinical presentation. Only 4 percent of patients had a single MH diagnosis. The remaining 96 percent had two or more MH conditions. Of the 160 women with PTSD,
only four had this as a sole diagnosis. All of the women with an alcohol and/or substance use disorder were dually diagnosed with one or more MH conditions. Additionally, 13 patients were diagnosed with some form of eating disorder.
Parental, Employment, and Housing Status
Because parental responsibility and job commitments could be factors affecting
participation in a treatment program lasting several weeks or months, we examined
the percentage of patients with responsibility for minor children and/or who were
employed at the time of admission. Approximately 16 percent of the 166 patients
were responsible for the care of minor children, and only approximately 5 percent
were employed. Nineteen percent of patients in our review were homeless at the
time of program admission.
Service Connection
Seventy-one percent of participants in our review were service-connected for any
condition (physical or mental health-related) and 55 percent were service-connected
for a MH condition.
VHA Treatment Preceding Program Admission
We reviewed aspects of patients MH care immediately prior to residential program treatment. We found almost 90 percent received outpatient VA MH treatment
in the 3-month period preceding program participation. Of the patients not in outpatient care just prior to admission, approximately two-thirds were either in another residential program or were receiving treatment on an acute mental health
unit. Most patients received outpatient treatment solely at a VA Medical Center
(VAMC) or a Community Based Outpatient Clinic (CBOC). Seventeen percent were
receiving treatment at more than one outpatient venue (e.g., VAMC and Vet Center).
More than three-quarters of the patients were engaged in two or more types of
outpatient treatment (individual therapy, group therapy, medication management,
mental health intensive case management, psychosocial rehabilitation recovery center programs) during the 3-month time frame. Seventy-two percent received individual therapy, 67 percent received medication management, and 37 percent participated in group therapy.
We reviewed the gender of outpatient MH providers seen prior to admission. Most
female patients (83 percent) received outpatient MH treatment from a female therapist or clinician during the 3-month period prior to program participation. Of the
138 patients seen for primary care, 75 percent were seen by a female primary care
provider, 8 percent by a male provider, and for 17 percent the gender of the provider
was unclear from the EHR.
Referral to Specialized Programs
From EHR review we categorized geographic referral patterns. Although three
programs largely served only patients from within the same VISN, most programs
drew patients from all areas of the country and these programs appeared to function
as a resource for nationwide referral of patients with an MST-related MH conditions.
Program Structure and Treatment Characteristics
Across programs, we found a diversity of structures, program emphases, and
treatment approaches through which programs address treatment of female veterans with MST related conditions. Treatments utilized varied by site, but generally
included either formalized evidence based therapies (EBPs), mixed therapies comprised of underlying treatment principles from different EBPs, or both, in conjunction with supportive therapies and medication management. Most sites offered cog-
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nitive processing therapy as the dominant approach for trauma processing but incorporated other EBPs into the curriculum.
For approximately 60 percent of patients, treatment planning documentation included provision of individual psychotherapy. In programs where individual therapy
was provided, we consistently found that the clinician providing the treatment was
female. All of the patients participated in one or more types of group therapy. At
some sites, clinicians told us that they saw the group milieu as central to the treatment process and therefore emphasized group-based over individual treatment. Both
male and female clinicians facilitated groups. We found that groups that focused on
discussion of patients trauma were usually led by female clinicians.
In recent years, VHA has increased emphasis on the use of peer support in the
recovery process. We found peer support technician documentation in the EHR (typically as a co-facilitator of a weekly recovery group) at some of the programs we reviewed.
There were differences in the philosophical stance towards same-gender treatment
versus mixed-gender treatment. Proponents of womens only treatment programs
argue the benefits of the psychological safety inherent in an all-female environment
as women veterans explore traumatic experiences. Other clinicians favor mixed-gender treatment. In this model, the presence of men is believed to be normalizing, prepares women to be better able to integrate into the real world environment after
program completion, and provides a means to help women confront their fears while
in a therapeutic environment. Some program staff we spoke to were in favor of a
blended approach. For example, a female veteran may start MST-related PTSD
treatment in an all-female environment, but as progress continues, the team may
incorporate male staff or add a mixed-gender group to the treatment plan so that
the patient can try out new challenges and increase exposure to stimuli that may
be typically avoided.
Aftercare
Our EHR review showed that aftercare (follow-up MH services after program discharge) was almost always arranged before women left the program. Generally,
aftercare was provided by the referring facility where the veteran had been receiving outpatient MH services prior to admission to the program. This was true whether the referring facility was a medical center, CBOC, Vet Center, or any combination of the above. We usually did not find that treating program staff remained engaged with the veteran after she returned home unless she received her outpatient
care at the same facility as the program. Ten women received aftercare from program therapists on an outpatient basis after they relocated to the area where the
program was located.
Twenty-two patients were readmitted to an inpatient unit or residential setting
within 30 days of program discharge. Three were admitted to medical units, 7 to
an acute psychiatry unit within 7 days of discharge and 12 went directly to another
MH Residential Rehabilitation Treatment Program program at discharge.
Outreach, Access, and Potential Actions to Enhance Program Utilization
Outreach and Utilization - Cohort based admissions involve admitting a group together and keeping the group intact through program completion in order to promote group cohesion. For cohort-based programs, capacity can be estimated by multiplying the number of beds by the number of cohorts offered annually. Program capacity is more difficult to determine with rolling admissions. During site visits and
from interviews with program leaders, we found that many of the available beds
were not occupied. This corresponds with data from VHAs Northeast Program Evaluation Center that indicates most of these programs do not maintain a full census.
A challenge commonly cited by facility staff related to maintaining an adequate volume of women veterans in the programs reviewed. Program staff indicated a need
for greater outreach to get the word out in order to attract an appropriate and
consistent stream of referrals.
Availability of Timely Program Resource Information - The MST Support Team
intranet site includes a list of inpatient/residential treatment resources for patients
with MST. During our site visits, some program staff noted discrepancies and/or
outdated information about their programs on the intranet site. The MST Support
Team periodically surveys programs to verify information posted is accurate, but
otherwise the team relies on facilities to report changes. Some program staff reported an inordinate amount of time spent reviewing and eliminating referrals inconsistent with program focus. Maintaining a current, accurate, coordinated resource list available with comprehensive program descriptions will serve to facilitate
awareness and outreach and increase the flow of appropriate referrals from VA clinicians and coordinators.
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Role of MST Coordinators - We met with MST Coordinators during our site visits
and frequently heard they had limited time (as little as 2 hours per week in some
cases) remaining for outreach activities and/or tracking of patients with positive
MST screens, which is a key component of their function as outlined by VHA policy.
This occurred because most MST Coordinators time was dedicated to direct patient
care responsibilities.
Aligning VHA MST and Travel Policies - We found that patients were referred
to programs in facilities outside of their Veterans Integrated Service Network
(VISN) and geographic region. During site visits, difficulties obtaining authorization
for patient travel funding was a consistent theme. From EHR review, we noted one
veteran whose start date was postponed to the next cohort as the referring facility
and treating facility were debating responsibility for transportation costs. One program with a wide national patient distribution indicated that having to pay for
roundtrip travel is a challenge, but putting patients first, the program had unilaterally decided to provide funding for bi-directional transportation.
A review of the current policy for MST and the current policy for Beneficiary
Travel reveals that the two do not align. The Beneficiary Travel policy indicates
that only selected categories of veterans are eligible for travel benefits and payment
is only authorized to the closest facility providing a comparable service. Those eligible for travel pay include veterans who: (1) travel for treatment related to a serviceconnected condition; (2) are service-connected at a rate of 30 percent or more for
treatment of any condition; (3) travel for Compensation and Pension examinations;
(4) receive a nonservice-connected pension; or (5) are low income as defined by income not in excess of the VA pension rate.
VHA requires that veterans and eligible individuals have access to residential or
inpatient programs that are able to provide specialized MST-related mental health
care, when clinically needed, for conditions resulting from MST. The MST Directive
also states that at a national level, there is a need to consider developing a number
of these programs as national resources and to arrange processes for referral, discharge, and follow-up. The directive requires that all health care for treatment of
mental and physical health conditions related to MST, including medications, is provided free of charge and that fee basis should be available when indicated.
We recommended that the Under Secretary for Health review existing VHA policy
pertaining to authorization of travel for veterans seeking MST-related MH treatment at specialized inpatient/residential programs outside of the facilities where
they are enrolled. VHA concurred with our recommendation and established a
workgroup to review issues and provide recommendations to the Under Secretary
for Health by April 30, 2013. As of VHAs last quarterly update in May 2013 to the
OIG on the implementation status of our recommendation, VHA reported the
workgroup was continuing its review.
CONCLUSION
The programs reviewed are a valuable resource available to serve clinically complex veterans with a history of MST and associated mental health and psychosocial
burden. VHA should establish a centrally coordinated, comprehensive, and descriptive MST program resource list; ensure that MST Coordinators have adequate time
to fulfill their outreach role; and review existing travel funding for this population.
These efforts may promote fuller utilization by those women veterans who have experienced MST and whose individual clinical course indicates the need for a more
intensive level of care than is available on an outpatient basis.
Mr. Chairman, thank you again for this opportunity to testify. I would be pleased
to answer questions that you or other Members of the Subcommittee may have.
f
Prepared Statement of Rajiv Jain, M.D.
Good morning, Chairman Benishek, Ranking Member Brownley, and Members of

the Committee. Thank you for the opportunity to discuss the Department of Veterans Affairs (VA) strong commitment to assisting Veterans who experienced sexual
trauma while serving on active duty or active duty for training. VA refers to these
experiences as military sexual trauma (MST). I am accompanied today by Dr. David
Carroll, Acting Chief Consultant for Mental Health Services; and Dr. Stacey Pollack,
National Mental Health Director of Program Policy Implementation both from the
Veterans Health Administration (VHA).
The statutory definition of MST comes from Title 38 United States Code, Section
1720D and is psychological trauma, which, in the judgment of a mental health professional employed by the Department, resulted from a physical assault of a sexual
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nature, battery of a sexual nature, or sexual harassment while the veteran was
serving on active duty or active duty for training. Sexual harassment is defined as
repeated, unsolicited verbal or physical contact of a sexual nature which is threatening in character.
VA is committed to ensuring eligible Veterans have access to the counseling and
care they need to recover from MST. Since the passage of Public Law 102585 in
1992, which added section 1720D to title 38, United States Code, VA has been developing and executing initiatives to: provide counseling and care to Veterans who
experienced MST; monitor MST-related screening and treatment; provide VA staff
with training on MST-related issues; and engage in outreach to Veterans about
available services.
All VA health care services (inpatient, outpatient, and pharmaceutical services)
for physical and mental health conditions related to experiences of MST are provided at no cost to Veterans. Veterans do not need to have a VA disability rating
or other documentation that the experience occurred to receive these services. Nor
do these Veterans need to be enrolled in VAs health care system to be eligible to
receive MST-related counseling and care under section 1720D. For fiscal year (FY)
2012 the total number of Veterans who received MST-related care was 85,474. This
is an increase of approximately 10.7 percent (from 77,198 in FY 2011). These Veterans had a total of 896,947 MST-related treatment encounters in FY 2012, which
represents an increase of approximately 13.1 percent (from 792,813 in FY 2011).
My written statement will describe how VA delivers high-quality, state-of-the-art
health care to Veterans who have experienced MST, provides education and training
for VA staff providing these services, collaborates with the Department of Defense
(DoD), and engages in outreach to Veterans who have experienced MST about services VA has available to assist them in their recovery.
I. VAs Capabilities to Provide MST-related Care
Organizational Structure
VA has an organizational infrastructure that oversees MST-related programming
at the national, regional, and facility levels. Every VA medical center has a designated MST Coordinator who serves as a point person for MST issues at the facility
and ensures that national and network-level policies related to MST screening,
treatment, monitoring, and education and training are implemented. MST Coordinators serve as contact persons for MST-related issues and can help Veterans find and
access VA services and programs. Network-level MST Points of Contacts monitor
implementation and facilitate communication at a regional level. At a national level,
the Veterans Health Administration (VHA) Office of Mental Health Services has
program responsibility for MST. The Office of Mental Health Services has a national
MST Support Team that monitors MST screening and treatment, oversees MST-related education and training, and promotes best practices in care for Veterans who
experienced MST. This MST Support Team also consults with VHAs Office of Mental Health Services on MST-related policy issues and responds to information requests from VA leadership and other stakeholders.
MST Screening
Recognizing that many survivors of sexual trauma do not disclose their experiences unless asked directly, it is VA policy that all Veterans seen for health care
at a VA facility are screened for experiences of MST. Screening is conducted in a
private setting by qualified providers who have been trained on how to screen sensitively and respond to disclosures. Veterans who report having experienced MST are
offered a referral to local mental health services for further assessment and/or treatment.
The proportion of Veterans screened for experiences of MST across all VHA facilities has increased every year since the national MST Support Team began monitoring it. In FY 2012, approximately 98.7 percent of Veterans seen in VHA outpatient care had a completed MST screen and all VHA facilities met or exceeded
the national MST screening target of 90 percent. In FY 2012, 72,497 or approximately 23.6 percent of female Veterans and 55,491 or approximately 1.2 percent of
male Veterans seen for health care at a VA facility had reported a history of MST
when screened by a VA health care provider.
MSTRelated Counseling and Treatment
Every VHA facility provides outpatient MST-related counseling and care to both
female and male Veterans. All Veterans seen in VA who screen positive for MST
are offered a referral for MST-related treatment. Because MST is an experience, not
a diagnosis, not all Veterans who screen positive will need or want treatment. In
FY 2012, approximately 72.9 percent of women who screened positive for MST re-
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ceived outpatient care for either a mental or physical health condition related to
MST; this rate was approximately 58.8 percent among men who screened positive.
Although VA provides free treatment for both physical and mental health conditions related to MST, my testimony focuses in particular on the mental health services that VHA has available for Veterans who experienced MST, as the majority of
the care that VHA provides related to MST is for mental health conditions. Specifically, in FY 2012, approximately 56.7 percent of women and 41.5 percent of men
who screened positive for MST received outpatient care for a mental health condition related to MST. All VHA health care facilities provide MST-related mental
health outpatient services, including psychological assessment and evaluation,
psychopharmacological treatment, and individual and group psychotherapy. In addition to general mental health services, specialty mental health services are also
available to target problems such as Post-traumatic Stress Disorder (PTSD), substance abuse, and depression. Every facility has providers who are knowledgeable
about mental health treatment for the aftereffects of MST. Because MST is associated with a range of mental health problems, VAs general services for PTSD, depression, anxiety, substance abuse, and others are important resources for MST survivors. In addition, many VA facilities have specialized outpatient mental health
services focusing specifically on sexual trauma. Many community-based Vet Centers
also have specially trained sexual trauma counselors.
For Veterans who need more intensive treatment, many VA facilities have Mental
Health Residential Rehabilitation and Treatment Programs (MHRRTP). VA also has
inpatient programs available for acute care needs (e.g., psychiatric emergencies and
stabilization, medication adjustment).
VAs Uniform Mental Health Services Handbook specifies that evidence-based
mental health care must be available to all Veterans diagnosed with mental health
conditions related to MST. The Office of Mental Health Services is currently conducting national initiatives to train VA clinicians in a number of evidence-based
practices for mental health treatment. Two of the therapies that are being disseminated, Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) are treatments for PTSD. There are also national training initiatives in Acceptance and
Commitment Therapy (ACT) and Cognitive Behavioral Therapy (CBT), which are
evidence-based psychotherapies for anxiety and depression, two mental health conditions that can result from the experience of sexual trauma. The training initiatives consist of experiential workshop training followed by ongoing clinical case consultation.
Because PTSD, depression, and anxiety are commonly associated with MST, these
national initiatives have been an important means of expanding MST survivors access to cutting-edge treatments. Furthermore, several of these treatments were
originally developed in the treatment of sexual assault survivors and have a particularly strong research base with this population. As such, the MST Support Team
has worked with each of these national initiatives to ensure inclusion of materials
relevant to MST survivors and to promote attendance by clinicians working with
MST survivors.
MST Readjustment Counseling Service (Vet Centers)
Veterans who experienced MST may also receive assessment, counseling, and referral services through Vet Centers run by VHAs Readjustment Counseling Service
(RCS). RCS is nearing its goal to have a qualified MST counselor on staff at each
of its 300 Vet Centers nationwide. To qualify to provide this special mental health
service at Vet Centers, the clinician must meet the criteria in the RCS MST Staff
Training and Experience Profile (STEP). The MST STEP criteria includes MST-related clinical education and supervision, as well as the professional licensure requirement in a mental health related field. All Vet Center clinical staff are required
to complete VAs mandatory training on MST.
In FY 2012, Vet Center staff supported over 5,400 Veterans with over 47,700 visits related to MST. This represents approximately a 25 percent increase in the number of Veterans and a 21 percent increase in the number of visits when compared
to the previous fiscal year.
II. MST-related Education for Staff
All VA mental health and primary care providers are required to complete mandatory training on MST. Also, VHAs national MST Support Team hosts monthly continuing education calls on MST-related topics that are open to all VA staff and
available online afterwards. Since 2007, the MST Support Team has hosted an annual, multi-day in-person training focused on MST-related program development as
well as the provision of clinical care to Veterans who experienced MST. The MST
Resource Homepage is a VA intranet community of practice Web site where VA staff
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can access MST-related resources and materials, review data on MST screening and
treatment, and participate in MST-related discussion forums. In addition, all VA
staff have access to an online independent study course on MST and other Webbased training materials.
Since 2008, the MST Support Team has engaged in national activities to support
and encourage facilities to host events as part of Sexual Assault Awareness Month
(SAAM) in April. These activities include the selection of a national theme, dissemination of support materials, publication of information about SAAM in the VAnguard magazine and other outlets, and hosting a special national MST training call
in April designed to be of general interest to VA staff. At a facility level, MST Coordinators may host medical education conferences and other educational presentations, distribute newsletters or fact sheets, and engage in other activities.
III. Outreach to Veterans
To help ensure information about MST-related services is readily available to Veterans, VA has developed outreach posters, handouts, and educational documents for
Veterans, secured inclusion of information about MST on relevant va.gov Web sites,
and developed an MST-specific Internet Web site (www.mentalhealth.va.gov/
msthome.asp). Also, VAs national MST Support Team has conducted an Answer
the Call campaign to ensure that Veterans calling VA medical centers with MSTrelated questions, including about initiating treatment, can reach the facility MST
Coordinator. Members of the team conduct test calls to VA medical centers in order
to verify that frontline staff such as telephone operators and clinic clerks are familiar with the terms military sexual trauma and MST, are readily able to identify
and direct callers to the MST Coordinator, and are sensitive to Veterans privacy
concerns. Facilities receive ratings of Satisfactory, Marginal, or Unsatisfactory based
on the results of calls; facilities with less than satisfactory ratings are provided with
additional feedback about team members experiences during the calls and are required to submit action plans to address problems identified.
VA has identified transitioning Servicemembers and newly discharged Veterans
as high priority groups for outreach in FY 2013. VA is collaborating with the Department of Defense (DoD) Sexual Assault Prevention and Response Office and
other national VA program offices to ensure that these Veterans are aware of MSTrelated services available through VHA.
At the facility level, MST Coordinators engage in local outreach efforts to raise
awareness about the availability of MST-related services. Tip sheets from the MST
Support Team help facilitate these efforts. MST is included in Make the Connection (www.maketheconnection.net) and About Face (www.ptsd.va.gov/aboutface)
Web sites featuring Veterans stories of recovery.
IV. MST Among Special Populations
VA produces annual reports on MST screening and treatment among Operation
Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND)
Veterans to help ensure adequate capacity is available to provide MST-related care
among this high-priority population. Among OEF/OIF/OND outpatients in FY 2012,
11,107 women (approximately 20.5 percent) and 3,256 men (approximately 0.9 percent) screened positive for MST. Among these Veterans with positive screens, approximately 60.4 percent of women and 53.0 percent of men received outpatient
MST-related mental health treatment in FY 2012.
VA also conducts annual special analyses on the rates of MST screening and
treatment among homeless Veterans. These analyses revealed that homeless Veterans who use VHA services have higher rates of experiencing MST compared to
all Veterans who use VHA. They also receive MST-related mental health care
through VA at higher rates, compared to all Veterans who use VA care. Among
homeless Veterans using VHA outpatient care in FY 2012, 6,890 (approximately
38.3 percent) women and 6,147 (approximately 3.5 percent) men reported MST.
Among these homeless Veterans with positive screens, approximately 87.3 percent
of women and 80.4 percent of men received outpatient MST-related mental health
treatment.
V. Capacity to Provide MSTRelated Care
VA monitors its capacity to provide MST-related mental health care among all
Veterans utilizing VA care. The monitoring data shows that all VA facilities provide
MST-related care to both female and male Veterans and all facilities have mental
health providers knowledgeable in the treatment of MST-related mental health conditions. MST-related mental health outpatient treatment rates for women and men
have increased every year since the VA began monitoring them.
The Office of Mental Health Services national MST Support Team conducted a
comprehensive analysis and determined that the minimum number of full-time
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equivalent employees (FTEE) required to meet the outpatient MST-related mental
health treatment needs of Veterans was 0.2 FTEE per 100 Veterans who screened
positive for MST. Comparison to this standard found that approximately 99 percent
of VHA facilities were at or above the target level. The MST Support Team has conducted follow-up with the facilities that did not meet the minimum staffing threshold, and those facilities have submitted action plans directed at improving their
staffing levels for MST-related mental health treatment.
More generally, the MST Support Team regularly provides technical assistance
and consultation to all facilities to ensure the highest capacity and quality of mental
health care for Veterans who have experienced MST. This includes developing materials to assist facilities in assessing strengths of their current programming, identifying gaps in services, and implementing best practices.
VI. Identifying Gaps In MST-related Services
The DoD and VA Integrated Mental Health Strategy (IMHS) derives from the
2009 DoD/VA Mental Health Summit and joint efforts in 2009 and 2010 between
DoD and VA subject matter experts. The IMHS includes 28 Strategic Actions (SA)
focused on establishing continuity between episodes of care, treatment settings, and
transitions between the two Departments. IMHS SA #28 was specifically tasked to
explore gaps in delivery and effectiveness of prevention and mental health care, for
women Veterans and for Veterans (both male and female) who experienced MST.
This workgroup is currently engaged in identifying disparities, specific needs, and
opportunities for improving treatment and preventive services for women Veterans
and Veterans who experienced MST. This workgroup includes VA and DoD clinicians, researchers, and other subject matter experts.
In addition to the work being done through IMHS SA #28, VA is in the midst
of focused efforts to address two other gaps in VAs MST-related services. First, 38
U.S.C. Section 1720D, as currently written, only authorizes VA to provide services
to Veterans who experienced sexual trauma while on active duty or active duty for
training. This does not include members of the National Guard or Reserves who
might have experienced sexual trauma while on weekend drill training. As such,
these Veterans are not eligible for free MST-related care through VA. Therefore, the
FY 2014 budget includes a legislative proposal to expand the population eligible for
free MST-related care through VA to those Veterans who experienced sexual trauma
while on inactive duty for training.
Finally, VAs Office of Inspector General (OIG) conducted an inspection to review
VHA services available to women Veterans who have experienced MST. In examining treatment through inpatient and residential programs, the VA OIG found that
women often needed to travel to programs outside their Veterans Integrated Service
Network in order to receive appropriate specialized care. However, travel funding
often served as a barrier to receiving this care, because Veterans who experienced
MST were not necessarily eligible to receive Beneficiary Travel funding through VA.
To better align Beneficiary Travel and MST policy, VA has established a workgroup
to make recommendations regarding this issue.
Conclusion
Mr. Chairman, our work to effectively treat Veterans who experienced MST continues to be a priority. VA remains focused on providing Veterans timely access to
high-quality health care services. We appreciate your support and encouragement
in identifying and resolving challenges as we find new ways to care for Veterans.
VA is committed to providing the high quality care which our Veterans have earned
and deserve. We appreciate the opportunity to appear before you today. My colleagues and I are prepared to respond to any questions you may have.
f
Prepared Statement of Dr. Karen Guice
Mr. Chairman, Members of the Committee, thank you for the opportunity to discuss the Military Health Systems roles and responsibilities in serving the medical
needs of survivors of military sexual trauma. Together, with our colleagues at the
Department of Veterans Affairs (VA), we provide the necessary health care and related services to ensure that appropriate care is timely, sensitive, and coordinated
for these individuals.
The Department of Defense is committed to ensuring our Service members, as
well as other survivors of sexual assault for whom we have responsibility, receive
comprehensive, high quality, and compassionate medical services where and when
they are needed worldwide, and this is what we will focus on today.
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We have, just this year, issued a new Department of Defense Instruction (DoDI),
6495.02, that establishes clear guidelines, standards and processes, along with
training and reporting requirements, to ensure that a structured, competent and coordinated continuum of health care and related services are available to every sexual assault survivor. This continuum of care begins when a survivor seeks health
care services in of our military treatment facilities and extends as they transition
to VA care. It is the Departments policy that survivors are treated with dignity and
respect, and that those that provide their health care are trained, competent and
readily available.
We require that health care is provided in a timely and standardized manner
across the Services. Sexual assault survivors who seek care at one our military medical treatment facilities will be treated as an emergency. This means that they will
be seen and examined immediately regardless of evidence of physical injury. Once
any emergency treatment has been provided, trained medical staff members talk to
the individual about sexual assault forensic exams and offer to perform the exam,
or arrange for the individual to get the exam elsewhere. The health care provider
also notifies the Sexual Assault Response Coordinator or Victim Advocate and arranges for any necessary and requested health care treatment. This includes appropriate testing and prophylactic treatment options for human immunodeficiency virus
(HIV) and other sexually transmitted diseases; access to emergency contraception;
referral to mental health services, as well as any follow on care for physical injuries.
When feasible, and with the individuals consent, subsequent medical management
and care is referred to the patients own primary care team to facilitate continuity
of care and support.
Procedures for conducting sexual assault forensic exams (SAFE) follow the current
U.S. Department of Justice Protocol and all medical providers are trained according
to this national standard. We require that all military medical treatment facilities
stock standardized SAFE kits and that our health care providers use these kits
when conducting an exam. Providers are also required to document their examinations using the most current edition of Department of Defense Form 2911 (DD 291),
DoD SEXUAL ASSAULT FORENSIC EXAMINATION REPORT. If the military
medical facility does not have appropriately trained providers available to conduct
the forensic exam, they must have an agreement with a local civilian facility. All
completed forensic exam specimens are properly labeled and provided to the appropriate Military Service law enforcement agency or Military Criminal Investigative
Organization, depending on the type of reporting requested by the survivor.
Sexual Assault Response Coordinators or SARCs have the primary responsibility
for coordinating care and services for survivors of military sexual assault and are
available to respond and speak to these individuals at any time. SARCs are also
responsible for counseling the individual on the choice between unrestricted and restricted reports, and for coordinating actions following the individuals reporting decision. When the individual elects to restrict reporting, confidentiality of information
is protected through the use of a restricted reporting control number for specimen
labeling following a forensic exam. This maintains the chain of custody for evidence
should the individual chooses to proceed with unrestricted reporting at a later date.
We have recently reviewed the Services compliance with policies and guidance
issued in the March 28, 2013 DoDI. The Services are in full compliance with the
provider availability and training standards. Sexual assault medical forensic examiners are available 24 hours a day, either within the MTF or through current signed
agreements with local civilian facilities. Each Service has written policies addressing the specific medical response requirements in accordance with the DoDI.
We recognize that the long-term needs of sexual assault survivors often extend
beyond the period in which a Service member remains on active duty. Ensuring that
these individuals have a successful and sensitive transition to services and care provided by the VA is essential. For those individuals leaving military service through
the Integrated Disability Evaluation System, ongoing health care needs are identified and information is provided about access to health care in the VA. Those military members who leave service outside of IDES receive in depth presentations
about VA health care and how to access those services through the Transition Assistance Program.
If the individual is still receiving behavioral health care at the time of separation
from the Service, s/he will be linked to the DoD inTransition Program to help ensure that continuity of care is maintained. This program assigns Service members
an inTransition support coach to bridge of support between health care systems and
providers through coaching assistance services by phone worldwide. The coach does
not deliver behavioral health care or perform case management, but is an added resource to health care providers and case managers and supports a seamless transition.
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In sum, our DoD health care policies are clear and the Military Departments have
been leaning forward and diligent in executing these policies and monitoring compliance. Our approach is structured and aligned with the responsibilities of other
stakeholders on military installations and within the community to include commanders, the personnel community, the legal community, law enforcement, and
local civilian authorities.
Mr. Chairman, Members of the Committee, I want to again thank you for the opportunity to appear before you today and discuss this very important issue.
f
Statements For The Record
THE AMERICAN LEGION
Sexual Assault results in sexual trauma. The Department of Veterans Affairs
(VA) reports that approximately one in five women and 1 in 100 men 1 have reported to their healthcare provider they have experienced sexual trauma while in
the military. In recent months, military sexual assault cases have dominated national headlines, and sexual assault victims are coming forward in droves. Every
sexual assault results in sexual trauma, which is sometimes suffered physically, and
nearly always suffered mentally.
VA provides treatment programs for veterans suffering from Post-Traumatic
Stress Disorder (PTSD) to address the mental anguish associated with military sexual trauma (MST). The problem is that VA doesnt have a separate program to work
with PTSD patients who contracted PTSD as a result of MST. The reason this is
a problem is because VAs PTSD therapy is a co-ed treatment program that groups
male and female patients together. Trying to address sexual trauma issues in a coed setting, in many cases is serving to further exacerbate symptoms and in some
cases discouraging patients from remaining in the program. Some female victims
have reported to The American Legion that this co-ed residential treatment program
is not conducive to their recovery, and that there is not enough separation of men
and women participating in the programs to feel confident they will not be victimized again even if sleeping areas are separate.
Nationwide, The American Legion has over 2,600 accredited service officers, which
enables us to receive real-time feedback of what is transpiring in the field. One service officer reports that one of his clients, a female veteran receiving treatment for
MST-related PTSD, was further traumatized while in the co-ed inpatient facility
when one of the male patients reached for a TV remote control that was sitting in
her lap. This seemingly benign incident illustrates the intensity of the issues faced
by victims of MST, and The American Legion fears that co-ed treatment may only
serve to exacerbate these issues in many, if not most cases.
VA has only seven residential treatment programs in the United States fully dedicated to women veterans specific to the treatment of PTSD. The American Legion
believes that the co-ed approach needs to be reconsidered, given the complications
associated with this particular issue, and that there should be an expansion of inpatient women veteran treatment programs, in order to address the issues unique to
sexual and PTSD trauma victims.
During The American Legions System Worth Saving site visit at the Coatesville
(Pa.) VA Medical Center (VAMC), we were briefed on a program that we believe to
be a model for women veterans, called the Power Program. The Power Program is
a residential dual diagnosis unit that provides inpatient and residential treatment
to eligible female veterans with substance abuse disorders, mental health problems,
and homelessness struggles. The programs mission is to prepare female veterans
for a lifestyle that supports continued recovery of mind, body and spirit. Patients
come from as far away as Denver, Colorado to enroll in the program, and female
veterans enrolled in the program stated that they receive excellent care and would
recommend the program to other women veterans.
PTSD and sexual trauma are major problems facing women veterans, and we recognize that outpatient programs have received funding and support, and have enjoyed recent expansion. Nevertheless, women veteran inpatient programs are still
lacking and women have to leave the local facility or region and their families
to receive care in a VA site across the country.
The American Legion believes that it is important to remember that this is not
an issue that only affects women; far from it. According to surveys of 14 VA medical
facilities conducted by The American Legion in the first half of 2013, nearly half
1 http://www.va.gov/WOMENVET/2011Summit/Breakout-ResourcesforMSTSurvivors2011.pdf
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of those being treated for MST were men. According to VA, while it is true that
MST proportionally affects more women than men, because of the disproportionate
ratio of men to women in the military there are actually only slightly fewer men
seen in VA that have experienced MST than there are women. 2 This fact is often
overlooked in the discussion of this issue. The American Legion believes that the
issues faced by all veterans should be considered and addressed, regardless of gender.
At our 2012 National Convention, The American Legion passed resolution number
295, entitled Military Sexual Trauma (MST), wherein we urged VA to ensure that
all VA medical centers, vet centers, and community-based outpatient clinics employ
a MST counselor to oversee the screening and treatment referral process, and to
continue universal screening of all veterans for a history of MST. While we recognize that this does not address the issue of the lack of facilities; victims may still
need to travel to a remote facility if they prove to be in need of treatment for MST.
We believe that a counselor at each facility will go a long way toward ensuring that
this issue gets the recognition it deserves, and that these veterans receive the care
they deserve. Furthermore, universal screening both recognizes that this is not an
issue which pertains to women only, and helps to reduce the stigma which may be
associated with MST.
All this, however, assumes that victims of MST are able to demonstrate serviceconnection for their MST-related PTSD, such that they are able to receive VA care
and/or compensation. In October 2008 the Government Accountability Office released a report entitled Additional Efforts Needed to Ensure Compliance with Personality Disorder Separation Requirements, which found that the Department of
Defense (DOD) was not doing enough to ensure that service members who were
being separated for various personalities were not wrongly denied recognition of a
traumatic brain injury (TBI), PTSD and/or MST which may have led to their discharge. Those who have these kinds of injuries as a result of their service may be
denied VA healthcare related to these injuries.
At the May 2013 National Executive Committee meetings, The American Legion
passed resolution number 26, entitled Mischaracterization of Discharges for
Servicemembers with Traumatic Brain Injury (TBI) and Post Traumatic Stress Disorder (PTSD) and Military Sexual Trauma (MST). Outlined in it is a short history
of the less than honorable discharge, which can be used to deny veterans benefits.
Unfortunately, discharges that results from a personality disorder diagnosis denies
the veteran any recourse toward receiving the treatment they may be entitled to,
if their condition is found to be service connected.
The American Legion is extremely concerned that a great many veterans who experience MST while in the service are being denied care in the VA system. The
character of the discharge resulting from the incident in service paradoxically prevents them from accessing care from the VA. The American Legion believes that
this must be changed.
In conclusion; in addition to the recommendations set forth in the resolve clauses
of the guiding resolutions attached to this testimony, The American Legion recommends more single sex treatment options, and offer care that is gender sensitive
and gender specific. We also call on VA to create more gender specific inpatient dormitories that are physically separated by enough physical structure to ensure the
reality, as well as the perception of safety for the patients is paramount. And finally, The American Legion calls on this committee to direct VA to carefully review
all claims for PTSD that indicate the possibility of sexual assault while on active
or reserve duties to ensure that they are not denied the care they need and deserve.
As this issue continues to develop, The American Legion looks forward to working
with the Committee, as well as DOD and VA, to find solutions. For additional information regarding this testimony, please contact Mr. Shaun Rieley at The American
Legions Legislative Division, (202) 8612700 or srieley@legion.org.
2 http://www.womenshealth.va.gov/WOMENSHEALTH/facts.asp
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NINETYFOURTH NATIONAL CONVENTION
OF
THE AMERICAN LEGION
Indianapolis, Indiana
August 28, 29, 30, 2012
Resolution No. 295: Military Sexual Trauma (MST)
Origin: Convention Committee on Veterans Affairs and Rehabilitation
Submitted by: Convention Committee on Veterans Affairs and Rehabilitation
WHEREAS, Military Sexual Trauma (MST) impacts thousands of brave men and
women in the Armed Forces; and
WHEREAS, In FY2010, Department of Defense (DOD) estimated that only 13.5
percent of MST incidents were reported; and
WHEREAS, In addition, reporting of MST is frequently followed by lackluster investigation and prosecution, with many resulting in administrative or dishonorable
discharge rather than Uniform Code of Military Justice prosecution; and
WHEREAS, DOD does not have a policy of permanently maintaining files of reported incidents of MST, creating evidentiary roadblocks for future Department of
Veterans Affairs (VA) claims; and
WHEREAS, A history of MST has correlations to many health and economic consequences, including PTSD, sexually transmitted infections, homelessness, and substance abuse; and
WHEREAS, According to a 2010 report published by the VA Office of Inspector
General, entitled Review of Combat Stress in Women Veterans Receiving VA
Health Care and Disability Benefits, Women Veterans Coordinators (WVCs) are
frequently underutilized due to lack of public awareness of the services and assistance provided by WVCs; and
WHEREAS, According to the same OIG report, women veterans are disproportionately granted Post Traumatic Stress Disorder (PTSD) claims based on MST; for instance, 9 percent of PTSD claims granted to women veterans by Veterans Benefits
Administration (VBA) were on the basis of MST, compared to only 0.1 percent of
male veterans; and
WHEREAS, MST claims and treatment involve delicate, sensitive emotional
issues; and
WHEREAS, VBA lacks a complete assessment of its system-wide MST-related
workload and outcomes, without which it cannot determine if additional MST-specific training and testing is necessary; now, therefore, be it
RESOLVED, By The American Legion in National Convention assembled
in Indianapolis, Indiana, August 28, 29, 30, 2012, That The American Legion
urge the Department of Defense (DOD) to improve its investigation and
prosecution of reported cases of Military Sexual Trauma (MST) to be on
par with the civilian system; and, be it further
RESOLVED, That The American Legion urge the DOD to examine the
underreporting of MST and to permanently maintain records of reported
MST allegations, thereby expanding victims access to documented evidence which is necessary for future Department of Veterans Affairs (VA)
claims; and, be it further
RESOLVED, That The American Legion urge the VA to ensure that all VA
medical centers, vet centers, and community-based outpatient clinics employ a MST counselor to oversee the screening and treatment referral process, and to continue universal screening of all veterans for a history of
MST; and, be it further
RESOLVED, That The American Legion urge the VA to review military
personnel files in all MST claims and apply reduced criteria to MST-related
PTSD to match that of combat-related PTSD; and, be it further
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RESOLVED, That The American Legion urge the VA to employ additional
Women Veterans Coordinators (WVCs) and to provide MST sensitivity
training to claims processors and WVCs; and, be it finally
RESOLVED, That The American Legion urge the VA to conduct an analysis of MST claims volume, assess the consistency of how these claims are
adjudicated, and determine the need, if any, for additional training and
testing on processing of these claims.
NATIONAL EXECUTIVE COMMITTEE
OF
THE AMERICAN LEGION
INDIANAPOLIS, INDIANA
MAY 8 9, 2013
Resolution No. 26: Mischaracterization of Discharges for Servicemembers

with Traumatic Brain Injury
(TBI) and Post Traumatic Stress Disorder (PTSD) and Military Sexual
Trauma (MST)
Origin: Veterans Affairs and Rehabilitation Commission
Submitted by: Veterans Affairs and Rehabilitation Commission
WHEREAS, In 1916, the military began using blue discharges which was a form
of administrative and less than honorable military discharge whereby
servicemembers were subsequently denied the benefits of the G.I. Bill by the Veterans Administration and had difficulty finding work because employers were aware
of the negative connotations of their blue discharge; and
WHEREAS, The American Legion lobbied the military and Congress in the original GI Bill legislation that led to the creation of an independent military discharge
review board as well as ensured servicemembers with blue discharges or other
than dishonorable discharges were entitled to their earned veterans benefits; and
WHEREAS, Later during the 1940s to early 1970s, the United States military
used Separation Personnel Codes (SPN) or spin codes to categorize
servicemembers based on discriminatory ailments or behavioral issues that had occurred during their military service; and
WHEREAS, These controversial SPN codes were later overturned through the
work of The American Legion and Congress as it unjustly prevented employers from
hiring veterans after their military service; and
WHEREAS, Today with the current conflicts in Operation Iraqi Freedom (OIF),
Operation Enduring Freedom (OEF) and Operation New Dawn (OND), the military
has again come under intense scrutiny by Congress, veteran service organizations
and the media for their discharge policies and reclassification of discharges as either
personality disorder, pre-existing and/or adjustment disorders, when these medical
conditions did not exist prior to a members service; and
WHEREAS, In February 2012, Madigan Army Medical Center servicemembers
were subjected to a forensic psychiatry team for several years to prevent them from
being discharged with a medical retirement due to post traumatic stress disorder
(PTSD) or other mental health illnesses incurred in service; and
WHEREAS, Then Senate Veterans Affairs Committee Chairman Patty Murray directed these 1,500 Madigan servicemembers to be reevaluated for their symptoms
and 285 of these cases were reversed to ensure they received the proper care and
benefits for their injuries and illnesses; and
WHEREAS, In October 2008, the Government Accountability Office (GAO) published a report, Additional Efforts Needed to Ensure Compliance with Personality
Disorder Separation Requirements, as well as a follow up study in September 2010
which found that DOD does not have reasonable assurance that its key personality
disorder separation have been followed by the military service branches; and
WHEREAS, It continues to remain unclear what each of the military service
branchs directives, policies and protocols are in place for administering personality
and adjustment disorders, particularly for servicemembers that are diagnosed with
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traumatic brain injury, PTSD, and/or who are victims of military sexual trauma;
now, therefore, be it
RESOLVED, By the National Executive Committee of The American Legion in regular meeting assembled in Indianapolis, Indiana, on May 89,
2013, That the Veterans Affairs and Rehabilitation Commission and National Security Commission staff conduct a study of existing Department of
Defense policies and procedures for character of discharge for
servicemembers that served during time of war and were susceptible or diagnosed with traumatic brain injury, post traumatic stress disorder, are
victims of military sexual trauma, and/or any other personality related disorders.
f
DISABLED AMERICAN VETERANS (DAV) on Behalf of The Independent
Budget
Messrs. Chairman and Members of the Subcommittee:
Thank you for inviting the DAV (Disabled American Veterans) to testify on behalf
of the Independent Budget Veterans Service Organizations (IBVSOs) at this oversight hearing. We appreciate the Subcommittees focus on the care and treatment
available to survivors of military sexual trauma (MST), and the current capabilities
of the Department of Veterans Affairs (VA) and Department of Defense (DoD) to
provide a structured and coordinated continuum of care to facilitate the recovery of
MST survivors, from the time of the incident through transition to veteran status.
This testimony is adapted from our discussion of MST in the Fiscal Year 2014 Independent Budget.
For a number of years, the IBVSOs have advocated greater collaboration between
VA and DoD to identify best practices for health care services and claims processing
for conditions related to MST. We also continue to express a fervent hope that DoD
is effectively addressing methods to prevent the incidence of sexual assaults and
harassment within all branches of the military services. We note legislation is pending in the Senate that would make changes related to the Uniform Code of Military
Justice related to our concern.
This topic is extremely sensitive to service members, veterans and the respective
Departments that are responsible for the safety and well-being of service members
and veterans. When a service member is wounded by enemy rifle fire or mortar
shrapnel in engagement with an enemy, as a society we recognize the sacrifice and
loss of our wounded military personnel; but when a military service member is injured from personal or sexual violence, often perpetrated by a fellow service member, military authorities and society in general respond in a very different way.
What is the Department of Defense (DoD) Doing About MST?

In 2005 DoD established the Sexual Assault Prevention and Response Office
(SAPRO) to ensure that each military service activity responsible for handling sexual assault complies with DoD policy. SAPRO serves as a single point of oversight
of these policies, provides guidance to service branches, and facilitates resolution of
common issues that arise in military services and joint commands. The objective of
SAPRO is to enhance and improve prevention through training and education programs, ensure treatment and support of victims, and enhance system accountability.
Through SAPRO, DoD has taken a number of steps to improve the situation that
confronts service members who have been personally assaulted. These include better
reporting, enhanced training and more complete information about the scope of the
problem and what needs to be done about it throughout the military command
structure.
According to SAPRO, 86.5% of sexual assaults go unreported, meaning that official documentation of many assaults may not exist. Prior to the new records retention laws passed in the 2011 National Defense Authorization Act (NDAA), the services routinely destroyed all evidence and investigation records in sexual assault
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cases after two to five years, leaving gaping holes in MST-related claims filed prior
2
to 2012. 1
The President signed an Executive Order in December 2011 that added Military
Rule of Evidence (MRE) 514 into military law which took effect on January 12,
2012. DoD views MRE 514 as a rule structured to protect the communications between a victim and a victims advocate when a case is handled by a military court.
This rule allows victims to trust that what is shared with professionals will remain
protected, whereas prior to the advent of MRE 514, DoD victim advocates and sexual assault response coordinators in some cases were compelled to testify about
their private communications with survivors. 3
Military sexual assault survivors are also informed by military authorities that
they now have a new option to request permanent or temporary transfers from their
assigned commands or bases, or to different locations within their assigned commands or bases. Procedures for this new expedited transfer option were issued in
December 2011. The Services were also directed to make every reasonable effort to
minimize disruption to the normal career progression of service members who report
that they are victims of sexual assault, and to protect victims from reprisal or threat
of reprisal for filing reports. 4
In April 2012 Secretary of Defense Panetta announced the establishment of independent special victims units to investigate incidents of MST in the military and
indicated that DoD would address some of its historic problems in archiving confirming records. Central to the proposed regulations is the elevation of the most serious reports to the attention of a Special Court Martial Convening Authority, a uniformed officer holding at least the rank of Colonel or equivalent. In addition to new
training for uniformed personnel and their commanders, the proposed regulations
include new centralized records of disciplinary proceedings stemming from these incidents, as well as more therapeutic outlets for survivors. 5 Also, DoD will require
that sexual assault policies be explicitly communicated to all service members within 14 days of their entry onto active duty. DoD has proposed that commanders be
required to conduct annual organizational climate assessments to measure whether
they are meeting the Departments goal of a culture of professionalism and maintaining zero tolerance for sexual assault within all commands; and that a mandate
will be enforced for wider public dissemination of available sexual assault resources,
such as DoDs Safe Helpline, www.safehelpline.org. 6
What Data Does DoD Possess on Reported Sexual Trauma?
Many service members who experience MST do not disclose it to anyone until
many years after the fact, but frequently exhibit lingering physical, emotional or
psychological symptoms. When service members experience sexual assault during
military service there are a number of unique factors that can prevent or discourage
them from coming forward and reporting the incident. 7
A report required by the FY 2011 NDAA for the period from October 1, 2011 to
September 30, 2012 (FY 2012) showed the military branches received a total of
1 Rachel Kimerling, PhD, Julie Karpenko, MSW; Military Sexual Trauma Support Team, VA
Office of Mental Health Services, National Center for PTSD, VA Palo Alto Health Care System;
Mental Health Care for Women Veterans and Treatment for Military Sexual Trauma,
PowerPoint
May
16,
2012
http://www.naswvc.com/attachments/article/82/
2012%20PTSD%20Dr.%20Kimerling.pdf
2 Testimony of Anu Bhagwati, Executive Director, Service Womens Action Network; U.S.
House of Representatives, Committee on Veterans Affairs, Subcommittee on Disability Assistance, Invisible Wounds: Examining the Disability Compensation Benefits Process for Victims
of Military Sexual Trauma, July 18, 2012 http://veterans.house.gov/witness-testimony/ms-anubhagwati-0
3 Witness Testimony of Col. Alan Metzler, Deputy Director, Sexual Assault Prevention and Response Office, U.S. Department of Defense; United States House of Representatives, Committee
on Veterans Affairs, Invisible Wounds: Examining the Disability Compensation Benefits Process for Victims of Military Sexual Trauma, July 18, 2012 http://veterans.house.gov/witness-testimony/col-alan-metzler
4 Ibid.
5 ABC News, Panetta Introduces Initiatives to Fight Sexual Assault in the Military, April
16, 2012 http://abcnews.go.com/blogs/politics/2012/04/panetta-introduces-initiatives-to-fightsexual-assault-in-the-military/
6 Lisa Daniel, American Forces Press Service, Panetta, Dempsey Announce Initiatives to Stop
Sexual Assault, April 16, 2012 http://www.defense.gov/news/newsarticle.aspx?id=67954
7 Garry Trudeau and Loree Sutton, The Washington Post, Breaking the Cycle of Sexual Assault in the Military, June 29, 2012 http://www.washingtonpost.com/opinions/breaking-thecycle-of-sexual-assault-in-the-military/2012/06/29/gJQAK0wNCWstory.html
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3,374 reports of sexual assault. Of these, 2,558 were unrestricted reports and 816
were restricted reports. This data represents a six percent increase since FY 2011. 8
Of the 1,713 alleged offenders under the legal authority of the Department, commanders had sufficient evidence to take disciplinary action against 66 percent of
them, an increase from 57 percent in FY 2009. Of those whose court-martials were
concluded in FY 2012, 79 percent were convicted of at least once charge, 19 percent
had charges dismissed, and 25 percent were granted a discharge or resignation in
lieu of court-martial. 9
What Data Does VA Possess on Veterans Who Report MST?
In its health care system, VA screens all enrolled patients for MST. National
screening data show that about one in five women and one in 100 men respond that
they had experienced MST.
According to VA for FY 2012, 23.6% of women (72,497) and 1.2 percent of men
(55,491) treated in VA facilities screened positive for MST. 72.9% of women who
screened positive for MST received outpatient MST-related care of any kind; 56.7%
received MST-related outpatient mental health care. 58.8% of men who screened
positive for MST received outpatient MST-related care of any kind; 41.5% received
MST-related outpatient mental health treatment.
Of OEF/OIF/OND veteran VHA users, 20.5% of women and 0.9% of men screened
positive. Among veterans with positive MST screens, 60.4% of women and 53.0% of
men received outpatient MST-related mental health treatment in FY 2012. According to VA this population utilizes MST-related mental health care at higher rates
than other Veterans, suggesting targeted outreach efforts to this population have resulted in higher utilization of VHA services.
These rates are almost certainly an underestimate of the actual rate of MST,
given that in general sexual trauma is frequently underreported. Also, these data
address only the rate of MST among veterans who have chosen to enroll in VA
health care; they do not address the actual rate for the veteran population in general. Although veterans who respond yes when screened are asked if they are interested in learning about MST-related services available, not every veteran necessarily consents to treatment. 10
Rates of veterans utilizing MST-related mental health outpatient care have been
increasing over time; and recently discharged veterans utilized MST-related mental
12
health services at higher rates than other veterans. 11
% of veterans with a positive MST screen who have at least one MSTrelated Mental Health encounter
Women
Men
All veterans
55.3%
39.6%
OEF/OIF/OND veterans
58.9%
51.0%
Homeless veterans who use VHA services also report higher rates of MST compared to all veterans and they receive MST-related mental health care at higher
rates compared to all veterans who use VA care. 13
8 Fact Sheet on DoD Sexual Assault Prevention & Response Strategic Plan & Annual Report
on Sexual Assault in the Military for FY 2012, May 7, 2013
9 Ibid.
10 Department of Veterans Affairs, National Center for PTSD, Military Sexual Trauma Fact
Sheet, August 2012 http://www.mentalhealth.va.gov/docs/mstgeneralfactsheet.pdf
PowerPoint
May
16,
2012
12 Amy Street, PhD; , VA Office of Mental Health Services, National Center for PTSD; VHA
Response to Military Sexual Trauma, PowerPoint Presentation, April 10, 2012.
PowerPoint
May
16,
2012
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Women
Men
% of homeless veteran VHA users with a positive screen for MST ..............................................
39.3%
3.3%
% of homeless veterans with a positive screen

for MST who have at least one MST-related MH
encounter .............................................................
88.9%
79.4%
What is VHA doing to Help Veteran Survivors of MST?

Every VA health care facility employs an MST coordinator to answer questions
veterans might raise about MST services. A variety of resources have been developed and distributed for the use of MST coordinators, including tip sheets, posters,
handouts, and contact cards. Emphasis has been placed on the importance of ensuring this information is available at key entry and access points (e.g., telephone operators, information desks, clinic clerks, facility websites). Each facility also has care
providers who are knowledgeable about treating MST patients. Many VA facilities
have developed specialized outpatient mental health services focusing specifically on
sexual trauma, and VAs 300 Vet Centers also offer sexual trauma counseling. VA
has almost two dozen programs nationwide that offer specialized MST treatment in
residential or inpatient settings for veterans who need more intense treatment and
support. Because some veterans are not comfortable in mixed-gender treatment settings, some facilities maintain separate programs for men and women; and all residential and inpatient MST programs require separate sleeping areas for men and
15
women. 14
What are the Challenges in VA for Veterans Who Experience MST?
According to VA, victims of MST present a wide variety of treatment needs. 16 Although posttraumatic stress disorder (PTSD) is commonly associated with MST, it
is not the sole diagnosis resulting from MST. Across a range of studies, VA research
indicates that men and women who report sexual assaults or harassment during
military service were more likely to be diagnosed with mental health challenges.
Women with MST had a 59 percent higher risk for mental health problems; the risk
among men was slightly lower, at 40 percent. 17 The most common conditions linked
to MST were depression, PTSD, anxiety, adjustment disorder, and substance-use
disorder. 18
In December of 2012, the Office of the VA Inspector General issued a health care
inspection report, Inpatient and Residential Programs for Female Veterans with
Mental Health Conditions Related to Military Sexual Trauma. The IG concluded
that women veterans were often admitted to specialized programs outside their Veterans Integrated Service Network (VISN) and that obtaining authorization for reimbursement of travel expenses was frequently cited as a problem for both patients
and staff. The Beneficiary Travel policy indicates that only selected categories of
veterans are eligible for travel benefits, and payment is authorized only from the
veterans home to the nearest facility providing a comparable service. The IG noted
the current directive is not aligned with the MST policy. The directive states that
patients with MST should be referred to programs that are clinically indicated regardless of geographic location. Some programs cited challenges maintaining an adequate volume of appropriate referrals; others reported to the IG that managing
women with eating disorders was a particular challenge. Additionally, many MST
Coordinators they interviewed reported that they had insufficient time to adequately meet their womens outreach responsibilities.
14 http://www.mentalhealth.va.gov/msthome.asp
PowerPoint
May
16,
2012
17 Department of Veterans Affairs, VA Research Currents. November-December 2008. http://
www.research.va.gov/resources/pubs/docs/varesearchcurrentsnov-dec08.pdf
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We concur with the IGs recommendations that the Under Secretary for Health
review existing VHA policy pertaining to authorization of travel for veterans seeking
MST related mental health treatment at specialized inpatient/residential programs
outside of the facilities where they are enrolled.
Although this Subcommittee is primarily focused on the coordinated continuum of
health care for MST survivors between DoD and VA, we offer our comments on the
Veterans Benefits Administrations (VBA) claims process for MST-related conditions
since there are several gaps that exist between the Departments that are of concern
to the IBVSOs and veterans. Many veterans indicate their frustration with the
claims process, particularly in cases when the sexual assaults were not officially reported. They express feeling re-traumatized in their efforts to gain help from VBA
even when they have provided significant evidence; statements from witnesses,
friends or family; detailed accounts of the incidents; along with VA and non-VA diagnostic and treatment recordsonly to see their claims denied.
Compensation and pension examinations can also be traumatic for veterans who
have been personally assaulted because examiners often require them to recount in
detail these devastating experiences, and to do so with someone uninvolved in their
VA care or therapy. These experiences often take years for veterans to overcome.
Veteran survivors of MST repeatedly tell us they should not be forced to repeat
their experiences about the trauma to strangers who often lack the sensitivity or
professional qualifications to counsel survivors of sexual trauma. The trust that is
built between an MST counselor or mental health provider and a patient is one that
should not be trivialized or ignored. Because of the special nature of these particular
conditions, VBA should employ the clinical and counseling expertise of sexual trauma experts within VHA or other specialized providers during the compensation examination phase. 19
In response to hearing continued complaints about disparities in MST-related
PTSD claims, VA acknowledged that due to the personal and sensitive nature of the
MST stressors in these cases, victims often fail to report or document the trauma
of sexual assault. If the MST event subsequently leads to post-service PTSD symptoms and a veteran files a claim for disability, the available evidence is often insufficient to establish the occurrence of a stressor event. To remedy this, VA developed
regulations and procedures that allow more liberal evidentiary documentation requirements and more sensitive adjudication procedures for these particular
claims. 20
In its new procedures and similar to adjudicating other PTSD claims, VBA initially reviews the veterans official military personnel records (including military
health records) for evidence of MST. According to VBA, such evidence may include:
1) DD Form 2910, Victim Reporting Preference Statement; and 2) DD Form 2911,
Sexual Assault Forensic Examination Report). Unfortunately, based on several
years of work in this field, the IBVSOs have ascertained that DD Forms 2910 and
2911 are not made part of service members official military personnel records, but
are retained in confidential files that have generally been unobtainable, even by a
survivor who filed them.
The VBA regulation also provides that evidence from sources other than service
records may support a veterans account of an incident, such as evidence from law
enforcement authorities; rape crisis centers; mental health counseling centers; hospitals; physicians; pregnancy tests; tests for sexually transmitted diseases; and
statements from family members, roommates, fellow service members, etc. 21
Documented behavioral changes are another type of relevant evidence that may
establish that an assault occurred, such as requests for reassignment; deterioration
in work performance; substance abuse; depression, panic attacks, or anxiety without
an identifiable cause; and unexplained economic or social behavioral changes. Veterans are requested to submit or identify any such evidence they may possess.
When this type of evidence is obtained, VA is required to schedule the veteran for
an examination with a mental health professional and requests an opinion as to
whether the claimed in-service MST stressor occurred. This opinion can serve to es-
19 Testimony of Anu Bhagwati, Executive Director, Service Womens Action Network; U.S.
House of Representatives, Committee on Veterans Affairs, Subcommittee on Disability Assistance, Invisible Wounds: Examining the Disability Compensation Benefits Process for Victims
of Military Sexual Trauma, July 18, 2012 http://veterans.house.gov/witness-testimony/ms-anubhagwati-0
20 Testimony of Thomas Murphy, Department of Veterans Affairs, Director of C&P Service,
U.S. House of Representatives, Committee on Veterans Affairs, Subcommittee on Disability Assistance, Invisible Wounds: Examining the Disability Compensation Benefits Process for Victims of Military Sexual Trauma, July 18, 2012 http://veterans.house.gov/witness-testimony/
mr-thomas-murphy-2
21 Ibid.
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tablish occurrence of the stressor, one element necessary for establishing service
connection. 22
VBA reports it is taking steps to assist veterans with resolution of these claims
and has placed a primary emphasis on informing VA regional office personnel of the
issues unique to MST, and is providing training in improved claims development
and adjudication. During August 2011, VBA reviewed a statistically valid sample of
approximately 400 MSTPTSD claims with the goal of assessing current processing
procedures and formulating methods for improvement. This led to development of
an enhanced training curriculum with emphasis on standardizing evidentiary development practices, as well as issuance of a new training letter and other information
to all VA regional offices. 23 The training focused on how to identify circumstantial
evidence (called markers) indicating that the claimed MST stressor may have in
fact occurred. As a result of these and other actions, VBA is reporting the post-training grant rate has risen from about 38 percent to over 50 percent. This change compares favorably with the overall PTSD grant rate of 5560 percent, according to
VBA. Additionally, in December 2012, VBAs national quality assurance office completed a second review of approximately 300 PTSD claims based on MST that were
denied following medical examination. The review showed an overall accuracy rate
of 86 percent, which is roughly the same as the current national benefit entitlement
accuracy level for all rating-related end products. 24
In addition to these general training efforts, VBA provided its designated Women
Veterans Coordinators with updated specialized training. These employees are located in every VA regional office and are available to assist both female and male
veterans with their claims resulting from MST. They also serve as a liaison with
the women veterans program managers at local VA health care facilities to coordinate any required health care. As a further means to promote adjudication of these
claims consistent with VAs regulation, VBA has recently created dedicated specialized MST claims processing teams within each VA regional office for exclusive handling of MST-related PTSD claims. Additionally, because the medical examination
process is often an integral part of determining the outcome of these claims, VBA
has worked closely with the VHA Office of Disability and Medical Assessment to ensure that specific training was developed for clinicians conducting PTSD compensation examinations for MST-related claims. 25
However, because earlier denied claims did not get the benefit of these new nationwide training resources, the Under Secretary for Benefits determined that VBA
would contact those veterans who had received denials and offer them an opportunity to have their claims re-adjudicated. The IBVSOs have been informed that
VBA has sent an outreach letter to 2,556 veterans who had been denied service-connection for MST-related conditions.
Unfortunately, VSOs were not notified prior to the letter being sent out to these
veterans. The IBVSOs asked VBA officials to inform us of the names of the veterans
for whom we hold Power of Attorney (POA), and thus represent, so that we can
properly assist them if they wish VBA to re-adjudicate their claims. VSOs are a critical partner in the claims process and ensuring that the veteran fully understands
what evidence is necessary or can support their claim, and to ensure these claims
are properly re-evaluated by VBA. We also note that the letter that went out contained no information about how VBA has tried to improve the processes, sensitivity
and understanding of MST related claims and minimal information about why VBA
was inviting re-evaluation of these claims. Finally, the IBVSOs pointed out the letter directs the veteran to contact his or her local regional office to request review
of their previously denied claim, but did not provide any contact information. While
we are pleased with the Under Secretary for Benefits efforts to improve claims processing for these complex claims we urge continued Congressional oversight to ensure VBA in fact has a consistent and comprehensive approach, throughout the system, to properly address these claims and more importantly set up a case management system to work with individual veteran survivors of MST in a more sensitive
22 Ibid.
23 Ibid.
24 Testimony of Curtis L. Coy, Deputy Under Secretary for Economic Opportunity, Veterans
Benefits Administration, Department of Veterans Affairs, United States Senate Committee on
Veterans Affairs, Pending Benefits Legislation Hearing, June 12, 2013 http://
www.veterans.senate.gov/hearings.cfm?action=release.display&releaseid=6d839502-3b01-4a1f9dd2-6292724455a0
25 Testimony of Thomas Murphy, Department of Veterans Affairs, Director of C&P Service,
U.S. House of Representatives, Committee on Veterans Affairs, Subcommittee on Disability Assistance, Invisible Wounds: Examining the Disability Compensation Benefits Process for Victims of Military Sexual Trauma, July 18, 2012 http://veterans.house.gov/witness-testimony/
mr-thomas-murphy-2
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manner so they that they are not re-traumatized during the claims process. For veterans without a VSO/ POA, having a designated person or point-of-contact in VBA
would make it much easier and more comfortable for the veteran to have questions
answered about correspondence from VBA regarding their claim.
What Are the Challenges Ahead?
Under DoDs confidentiality policy, military victims of sexual assault can file a restricted report and confidentially disclose the details of the assault to specified individuals and receive medical treatment and counseling, without triggering any official criminal or civil investigative process. Despite the progress on the VAs part to
include SAPRO information in its M211 manual, to maintain confidentiality in the
case of restricted reporting, DoD policy prevents release of MST-related records with
limited exceptions. However, VA is not specifically identified as an exception for
release of records in DoDs policy, and it is unclear if VA could gain access to these
records even with permission of a veteran survivor. One of the IBVSOs primary
concerns is that VA be able to access restricted DoD records (with the veterans permission) documenting reports of MST for an indeterminate period. To establish service connection for PTSD there must be credible evidence to support a veterans assertion that the stressful event actually occurred. Restricted records are highly credible resources but it is questionable if they are readily available, even with the consent of the veteran. With the veterans authorization, the IBVSOs believe DoD
should provide VA adjudicators access to all MST records, whether restricted or unrestricted, to aid VBA in adjudicating these cases.
The IBVSOs strongly believe that survivors of sexual assault during military service deserve recognition and assistance in developing their claims and compensation
for any residual conditions found related to the assault. These cases need and deserve special attention and due to the circumstances of these injuries, and survivors
who have courageously come forward need to be consistently and fairly recognized
by the government.
The IBVSOs are pleased with the progress VA has made with the increased attention on MST-related information that encourages veterans to have more informed
conversations with VA staff about the many available services, benefits, and treatment options. On the other hand, while DoD is moving more forcefully to stem sexual assault events in the ranks, DoD and VA need to resolve their differences with
regard to MST-related records availability, both to VA health care professionals and
to VBA adjudicators.
Summary
The Subcommittee expressed interest in learning about the coordinated efforts between DoD and VA regarding a continuum of care to facilitate recovery of MST survivors from the point-of-incident through veteran status. The IBVSOs have no
knowledge that a structured or defined program exists between the two Departments in this regard. SAPRO governs how each of the military services under DoD
handles sexual trauma reporting options and access to treatment, but each of the
military branches is responsible for developing its own sexual assault and response
prevention campaign to address this pressing issue. The IBVSOs are unaware of
any specific protocol for interagency hand-off of MST survivors, but we note that
DoD included in the revised April 2013 Sexual Assault Prevention and Response
Strategic Plan the goal of collaborating with VA and the veterans service organization community to develop a victim continuity of care protocol for service members
who are being discharged from military service due to sexual assault. The IBVSOs
are supportive and urge the implementation of this plan, and we look forward to
working with DoD to accomplish it. We also recommend that DoD, VA, or both agencies inform a service member following the report of a sexual assault, or prior to
discharge, about the benefits and health care services that are available in VA, and
to offer assistance in connecting with an MST coordinator at a local VA medical facility or Vet Center.
For the Subcommittees purposes, the IBVSOs have developed a number of recommendations for Congress, VBA and VHA in improving health care and benefits
procedures related to MST treatment and benefits claims. To conclude our testimony, we offer those recommendations for the Subcommittees consideration:
We urge VBA to identify and map all claims by gender related to personal trauma with a focus on MST to determine the number of claims submitted annually,
their award rates, denial rates, and the conditions most frequently associated
with these claims, and to make this information available to the public.
VBA must properly train its claims staff to be compliant with the VBA procedures and policies intended to assist veterans in producing fully developed
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claims; and VBA should conduct continued oversight to review these claims to
ensure the directives that have been issued are in fact being followed.
Given the complexity of MST-related claims, VBA should revise the current
work credit system for rating specialists, which seems to reward speed over accuracy in claims determinations, to ensure these particular claims related to
MST are adequately researched and properly resolved.
VBA should establish a designated person or point-of-contact in VBA for veterans to have questions answered about correspondence from VBA regarding
their MST-related claims.
VA should establish a presumption of soundness of MST-related diagnoses
made by VAs own physicians and counselors who are caring for MST survivors
in VA facilities; VBA claims reviewers should not be enabled to second-guess
evaluations by these VA medical and counseling professionals, or to discount established and official VA treatment records, in favor of single point-in-time compensation and pension evaluations made by contract examiners who may be unfamiliar with the nuances associated with MST.
The Under Secretary for Health review existing VHA policy pertaining to authorization of travel for veterans seeking MST related mental health treatment
at specialized inpatient/residential programs outside of the facilities where they
are enrolled.
DoD and VA need to resolve their differences with regard to MST-related
records availability, both to VA health care professionals and to VBA adjudicators.
Congress should continue its oversight and hearings to stimulate VA and DoD
to improve their policies and practices for MST care and claims compensation.
Given the dual nature of this problem as pointed out in our testimony, and the
obstacles that affect both health care and benefits of MST survivors, the
IBVSOs urge this Subcommittee to coordinate closely with the Subcommittee on
Disability Assistance and Memorial Affairs, as well as the Committee on Armed
Services, in a combined effort to find ways to further improve VAs coordination
with DoD on these difficult and challenging cases.
Mr. Chairman and Members of the Subcommittee, this concludes my testimony
on behalf of the Independent Budget veterans service organizations.
f
Questions For The Record
Health, To: Hon. Eric K. Shinseki, Secretary, U.S. Department of Veterans
Affairs
July 24, 2013

The Honorable Eric K. Shinseki
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Mr. Secretary:
In reference to our Subcomittee on Health hearing entitled, Safety for Survivors:
Care and Treatment for Military Sexual Trauma that took place on July 19, 2013,
I would appreciate it if you could answer the enclosed hearing questions by the close
of business on August 26, 2013.
In an effort to reduce printing costs, the Committee on Veterans Affairs, in cooperation with the Joint Committee on Printing, is implementing some formatting
changes for materials for all Full Committee and Subcommittee hearings. Therefore,
it would be appreciated if you could provide your answers consecutively and singlespaced. In addition, please restate the question in its entirety before the answer.
Due to the delay in receiving mail, please provide your response to Jian Zapata
at jian.zapata@mail.house.gov. If you have any questions, please call (202) 225
9756.
Sincerely,
Julia Brownley
Ranking Member
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Subcommittee on Health
JB:cw
f
Questions from Rep. Dina Titus
Questions for Rajiv Jain M.D., Assistant Deputy Undersecretary for Patient Care Services, Office of Patient Care Services, VHA, VA
1. As Ranking Member of the Disability Assistance Subcommittee, I am working
every day to improve VBA. On this issue, VBA plays a role along with VHA to provide the support veterans need.
a. What is the extent of the coordination between VHA and VBA on issues of military sexual trauma?
b. What can be done to improve this coordination?
c. What information is provided to veterans who are victims of MST to ensure
they are aware of benefits that may be available through VBA?
f
Health, To: Hon. George J. Opfer, Inspector General, Department of Veterans Affairs
July 24, 2013
The Honorable George J. Opfer
Inspector General
Department of Veterans Affairs
Office of Inspector General (50)
810 Vermont Avenue, NW
Washington, DC 20420
Dear Mr. Opfer:
In reference to our Subcomittee on Health hearing entitled, Safety for Survivors:
Care and Treatment for Military Sexual Trauma that took place on July 19, 2013,
I would appreciate it if you could answer the enclosed hearing questions by the close
of business on August 26, 2013.
In an effort to reduce printing costs, the Committee on Veterans Affairs, in cooperation with the Joint Committee on Printing, is implementing some formatting
changes for materials for all Full Committee and Subcommittee hearings. Therefore,
it would be appreciated if you could provide your answers consecutively and singlespaced. In addition, please restate the question in its entirety before the answer.
Due to the delay in receiving mail, please provide your response to Jian Zapata
at jian.zapata@mail.house.gov. If you have any questions, please call (202) 225
9756.
Sincerely,
Julia Brownley
Ranking Member
Subcommittee on Health
JB:cw
f
Questions from Rep. Dina Titus
Questions for Michael Shepherd M.D., Office of the Inspector General, VA

1. What types of investigations do you perform at individual VA health facilities
to ensure that MST services are being provided in the most effective and time efficient way possible? For example, what will you do to examine the newly opened VA
hospital in Southern Nevada?
2. One of your recommendations to VHA was to establish a centrally coordinated,
comprehensive, and descriptive MST program resource list. What has been the re-
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sponse from the VA? Please elaborate as to how you see such a clearinghouse being
structure.
3. VA policy requires that veterans who have MST-related PTSD be informed that
they may use information from sources other than their service records to establish
credible evidence of the stressors from MST they have endured before VA can deny
their claim.
a. In your observation and experience with MST cases, is this being done?
b. How is this policy playing out when veterans attempt to bring this evidence
to bear?
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House Hearing, 113TH Congress - Safety For Survivors: Care and Treatment For Military Sexual Trauma

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SAFETY FOR SURVIVORS: CARE AND TREATMENT

FOR MILITARY SEXUAL TRAUMA

COMMITTEE ON VETERANS AFFAIRS

FRIDAY, JULY 19, 2013

Serial No. 11331

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COMMITTEE ON VETERANS AFFAIRS

MICHAEL H. MICHAUD, Maine, Ranking

HELEN W. TOLAR, Staff Director and Chief Counsel

JULIA BROWNLEY, California, Ranking

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STATEMENTS FOR THE RECORD

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The American Legion ..............................................................................................

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QUESTIONS FOR THE RECORD

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Letter From: Hon. Julia Brownley, Ranking Member, Subcommittee on

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SAFETY FOR SURVIVORS: CARE AND

U.S. HOUSE OF REPRESENTATIVES,

Mr. BENISHEK. Good morning, everyone. The Subcommittee will

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Ms. BROWNLEY. Thank you, Mr. Chair.

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Subcommittee will also be looking at the coordination of care and

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Ms. WILKEN. Thank you. I am a United States Air Force veteran.

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Mr. BENISHEK. Thank you very much for your testimony.

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Mr. JOHNSON. Chairman Benishek, Ranking Member Brownley,

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